Dementia and depression Flashcards
What are the effects of normal ageing on the brain?
Structure:
Global decrease in weight and volume of the brain
Ventricle size increases.
Decreased grey matter.
Nerve cell loss in the cortex, hippocampus, cerebellum and fewer cell synaptic connections.
New deposits: tau tangles, plaques (amyloid), lewy bodies (intracellular inclusions)
Function:
- IQ declines after 60 then declines (performance > verbal).
- Working memory declines.
- Problem solving deteriorates- difficulty applying information to new situations
- Decreased cognitive flexibility
What is delirium?
Acute confusional state/brain failure
Fluctuating
Inattention
Disturbance of consciousness- clouding to coma
Acute onset- short period of time.
Changes in:
perception [hallucinations],
disorganised thinking/cognition,
memory,
sleep wake-cycle,
psychomotor,
behavioural
Affects all ages, most common in elderly
Causes of delirium?
PInCHES ME
- Pain
- Infection- urosepsis, pneumonia
- Constipation
- Hydration + urinary retention
- Environment- new
- Surgery
- Medication and drugs
- Anticholinergics- oxybutinin
- benzodiazepines/alcohol/drugs
- withdrawal of benzodiazepines/alcohol/drugs
- Electrolyte derangement
Some people are more predisposed- think about how severe cause needs to be to precipitate delirium
What is the epidemiology of delirium?
Prevalence in hospitalised medically ill patients ranges from 10-31%.
Most delirium occurs in the first 7-10 days of admission or within days of surgery.
Up to 50% of postoperative patients develop delirium, with patients at increased risk if they have had cardiac surgery, hip surgery, or transplantation.
Delirium is also commonly reported to occur in nursing homes, but is uncommon in community populations.
How is delirium managed?
Assessment.
Treatment of underlying condition.
Environmental management.
Monitor regularly.
Tranquillisation? only if absolutely necessary.
Manage acute distress, reorientate
How is dementia diagnosed? What steps are needed to assess dementia?
Dementia triad: cognitive impairment/ memory loss; irreversibility; functional impairment.
ICD-10 criteria.
Steps for assessment:
- History
- Mental state examination- AMTS
- Cognitive test- MMSE, ACEIII, RUDAS
- Physical exam - parkinsonism
- Blood test
- EEG
- Brain imaging- CT/MRI
What are the ICD-10 criteria for dementia diagnosis? [not in lecture]
Chronic/progressive brain syndrome.
Disturbed higher cortical functions including memory, thinking, orientation, comprehension, calculation, learning, language and judgement.
Intact consciousness
Deterioration in emotional control, social behaviour or motivation.
How is cognition/consciousness assessed? [not in lecture]
Glasgow Coma Scale GCS/15: motor (obeys commands); verbal (oriented, converses); eyes (spontaneously open).
Orientation: TPP /3.
AMTS/10: time, year, place, age, DOB, recall, people, WW1, PM, countdown; screening test for confusion.
Mini mental state examination /30, or MOCA.
Full cognitive assessment.
What questions are asked in a mini mental state examination (MMSE), cognitive assessment? [not in lecture]
5 time + 5 place
5 7s
6 registration + recall
6 read, repeat, write, draw, name
3 step process
Draw clock
Frontal lobe: proverbs, vocabulary, executive thinking, sequencing.
No prompting.
What are the side effects of biomedical treatments for dementia? [not in lecture]
Consider acetylcholinesterase inhibitors donepezil, galantamine and rivastigmine (patch) for mild or moderate Alzheimer’s disease (MMSE <26pts)
SE: GI upset, headache, dizziness. Review effectiveness (MMSE) 6 monthly by GP. Can be stopped quickly if adverse reaction.
What are BPSD (behavioural and psychological symptoms of dementia)? [not in lecture]
Behavioural: apathy, agitation, wandering, restlessness, disinhibition, pacing, screaming, night crying, mannerisms.
Psychological: depression, anxiety, insomnia, delusions, hallucinations, misidentification.
Physical, activity related, intrinsic to dementia, depression and delusions?
How are BPSD (behavioural and psychological symptoms of dementia) treated? [not in lecture]
Reality orientation.
Memory enhancement.
Cognitive stimulation.
Psychological therapies, e.g. CBT.
Occupational therapy.
Social services care.
Day hospitals.
Respite care/ support for carers- Admiral.
[not in lecture]
What are biomedical treatments for behaviour that challenges in dementia?
Risks?
Consider medication only if there is severe distress or an immediate risk of harm to the person with dementia or others. Consider risk of CVA/ death.
Antipsychotics given over 3-16 weeks modestly better than placebo for behaviour.
Risperidone and olanzapine beneficial for aggression.
Low dose, review regularly (6 weeks).
Risk of stroke ? all antipsychotics. ? hasten cognitive decline.
Do not use in Lewy body dementia because of risk of severe adverse reactions.
Depression/anxiety: antidepressants.
Agitation: avoid antipsychotics, antiCh, benzodiazepines, mood stabilisers. Delusions/hallucinations: antipsychotics.
What is diagnostic of a depressive episode?
> Two weeks of two of the core symptoms:
- Low mood
- Low energy/motivation
- Anhedonia
and two [mild] or more [moderate] of these six symptoms=
- weight/appetite change and loss
- sleep change- insomnia +early morning waking/hypersomnia
- psychomotor disturbance- agitation, retardation
- feelings of worthlessness/guilt- inappropriate/excessive
- impaired concentration/indecisiveness
- Recurrent thoughts of death/ suicidality.
Effect on life
What must be excluded in assessment of depression?
Organic causes: Drugs: beta blockers, digoxin, anti epileptics
Conditions: Cushing’s, Addison’s, hypothyroidism, hypercalcaemia (psychic moans), folate deficiency, anaemia, neurological disturbance.
How is depression managed?
Biological: antidepressants = SSRI (fluoxetine, citalopram, paroxetine), SNRI (venlfaxine, duloxetine, mirtazepine), TCA (amitryptilline, dosulepin)
Electroconvulsive therapy.
Psychological: CBT/ psychotherapy.
Social interventions-sleep hygiene etc.
When is electroconvulsive therapy indicated?
Severe depressive illness.
Catatonia.
Severe manic episode.
Also treatment resistant schizophrenia.
Procedure: GA, muscle relaxants, EEG monitoring.
Aetiology of depression/Risk/Contributing factors
Depressogenic stressors
Prolonged stress
Recuperative- energy conserving response
Inflammatory state
Genetics and environmental factors
low self worth
cognitive bias
sleep
self isolation
Assessing depression
Single episode/recurrent
Precipitating factors
Other psych comorbidities
Self care
Risk- self harm/suicide
Protective factors
Depression in elderly
- Catatonia more likely
- More biological/physical symptoms
- Can look like dementia- pseudodementia
What are the psychosocial problems that come with ageing?
Fear of death
Bereavement
Illness
Financial issues
Loss of independence
Social isolation
What is the definition of dementia?
Progressive global decline in higher cortical functions of brain
Associated with emotional and behavioural symptoms
What is the epidemiology of dementia?
Increasing prevalence with age
One percent= sixty five- sixty nine year olds
Twenty percent= eighty five to eighty nine year old
What are the main types of dementia?
- Alzheimer’s
- Lewy Body
- Vascular
- Frontotemporal
Features of Alzheimer’s disease? Which part of brain affected? Pathophysiology?
Insidious onset
Memory problems
Entorhinal cortex + medial temporal lobe [hippocampus]
Tau and amyloid plaques
What are the features of early onset Alzheimer’s disease?
Aphasia/agraphia/alexia
< 65 years old
Rapid progression
Treatment of Alzheimer’s disease
- Acetylcholineesterases [increase ACh in synapse]- donepezil, galantamine, rivastigmine
- NMDA antagonist- memantine
Non disease modifying
What is vascular dementia?
Who gets vascular dementia?
Presentation?
CT?
Where in brain?
Treatment?
Multi infarct dementia
Previous TIA/stroke/vascular risk factor
Step wise deterioration
Small white spots
Watershed areas between cerebral arteries
No treatment- manage vascular risk factors
What is Lewy Body dementia?
Onset less than one year of onset of Parkinson’s- Parkinsonism
- Visual hallucinations
- Fluctuating awareness/attention
- REM sleep disorder
What is frontotemporal dementia? Who gets it/epidemiology? Features
Pick’s disease- affects frontal lobes
Rare- two percent of dementia
Often early onset- Twenty percent of early onset dementia [<65y]
Pick bodies Disinhibition, personality change, emotional lability/blunting
What are other types of dementia?
Parkinson’s disease related
Huntington’s disease related
CJD related [mad cow disease, rapid progression]
Trauma
Alcohol
HIV related
SLE related
Wilson’s disease
What are reversible causes of suspected dementia?
- Normal pressure hydrocephalus
- Hypothyroidism
- Vitamin B12 deficiency
- Neurosyphilis
- Pseudodementia [depression]
What is the triad of symptoms of normal pressure hydrocephalus?
Dementia
Ataxia
Urinary retention
Which is not a core symptom of depression?
a] low energy
b] lack of interest in activities
c] feeling of worthlessness
c] feeling of worthlessness
Impairment in which of these MMSE criteria most suggest delirium? a] Months of year backwards b] Short term recall of address c] Date of WWII
a] Months of year backwards - lack of attention= will get distracted halfway through
Dementia and delirium table
Onset
Age
Course
Cause
Hallucinations/delusions?
Cognitive impairment?
> Inattention/distraction
Psychomotor symptoms
Consciousness?
Treatment
