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DPD 2020 > Dementia and depression > Flashcards

Dementia and depression Flashcards

1
Q

What are the effects of normal ageing on the brain?

A

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
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2
Q

What is delirium?

A

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

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3
Q

Causes of delirium?

A

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

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4
Q

What is the epidemiology of delirium?

A

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.

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5
Q

How is delirium managed?

A

Assessment.

Treatment of underlying condition.

Environmental management.

Monitor regularly.

Tranquillisation? only if absolutely necessary.

Manage acute distress, reorientate

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6
Q

How is dementia diagnosed? What steps are needed to assess dementia?

A

Dementia triad: cognitive impairment/ memory loss; irreversibility; functional impairment.

ICD-10 criteria.

Steps for assessment:

  1. History
  2. Mental state examination- AMTS
  3. Cognitive test- MMSE, ACEIII, RUDAS
  4. Physical exam - parkinsonism
  5. Blood test
  6. EEG
  7. Brain imaging- CT/MRI
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7
Q

What are the ICD-10 criteria for dementia diagnosis? [not in lecture]

A

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.

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8
Q

How is cognition/consciousness assessed? [not in lecture]

A

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.

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9
Q

What questions are asked in a mini mental state examination (MMSE), cognitive assessment? [not in lecture]

A

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.

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10
Q

What are the side effects of biomedical treatments for dementia? [not in lecture]

A

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.

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11
Q

What are BPSD (behavioural and psychological symptoms of dementia)? [not in lecture]

A

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?

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12
Q

How are BPSD (behavioural and psychological symptoms of dementia) treated? [not in lecture]

A

Reality orientation.

Memory enhancement.

Cognitive stimulation.

Psychological therapies, e.g. CBT.

Occupational therapy.

Social services care.

Day hospitals.

Respite care/ support for carers- Admiral.

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13
Q

[not in lecture]

What are biomedical treatments for behaviour that challenges in dementia?

Risks?

A

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.

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14
Q

What is diagnostic of a depressive episode?

A

> 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

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15
Q

What must be excluded in assessment of depression?

A

Organic causes: Drugs: beta blockers, digoxin, anti epileptics

Conditions: Cushing’s, Addison’s, hypothyroidism, hypercalcaemia (psychic moans), folate deficiency, anaemia, neurological disturbance.

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16
Q

How is depression managed?

A

Biological: antidepressants = SSRI (fluoxetine, citalopram, paroxetine), SNRI (venlfaxine, duloxetine, mirtazepine), TCA (amitryptilline, dosulepin)

Electroconvulsive therapy.

Psychological: CBT/ psychotherapy.

Social interventions-sleep hygiene etc.

17
Q

When is electroconvulsive therapy indicated?

A

Severe depressive illness.

Catatonia.

Severe manic episode.

Also treatment resistant schizophrenia.

Procedure: GA, muscle relaxants, EEG monitoring.

18
Q

Aetiology of depression/Risk/Contributing factors

A

Depressogenic stressors

Prolonged stress

Recuperative- energy conserving response

Inflammatory state

Genetics and environmental factors

low self worth

cognitive bias

sleep

self isolation

19
Q

Assessing depression

A

Single episode/recurrent

Precipitating factors

Other psych comorbidities

Self care

Risk- self harm/suicide

Protective factors

20
Q

Depression in elderly

A
  • Catatonia more likely
  • More biological/physical symptoms
  • Can look like dementia- pseudodementia
21
Q

What are the psychosocial problems that come with ageing?

A

Fear of death

Bereavement

Illness

Financial issues

Loss of independence

Social isolation

22
Q

What is the definition of dementia?

A

Progressive global decline in higher cortical functions of brain

Associated with emotional and behavioural symptoms

23
Q

What is the epidemiology of dementia?

A

Increasing prevalence with age

One percent= sixty five- sixty nine year olds

Twenty percent= eighty five to eighty nine year old

24
Q

What are the main types of dementia?

A
  • Alzheimer’s
  • Lewy Body
  • Vascular
  • Frontotemporal
25
Q

Features of Alzheimer’s disease? Which part of brain affected? Pathophysiology?

A

Insidious onset

Memory problems

Entorhinal cortex + medial temporal lobe [hippocampus]

Tau and amyloid plaques

26
Q

What are the features of early onset Alzheimer’s disease?

A

Aphasia/agraphia/alexia

< 65 years old

Rapid progression

27
Q

Treatment of Alzheimer’s disease

A
  • Acetylcholineesterases [increase ACh in synapse]- donepezil, galantamine, rivastigmine
  • NMDA antagonist- memantine

Non disease modifying

28
Q

What is vascular dementia?

Who gets vascular dementia?

Presentation?

CT?

Where in brain?

Treatment?

A

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

29
Q

What is Lewy Body dementia?

A

Onset less than one year of onset of Parkinson’s- Parkinsonism

  • Visual hallucinations
  • Fluctuating awareness/attention
  • REM sleep disorder
30
Q

What is frontotemporal dementia? Who gets it/epidemiology? Features

A

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

31
Q

What are other types of dementia?

A

Parkinson’s disease related

Huntington’s disease related

CJD related [mad cow disease, rapid progression]

Trauma

Alcohol

HIV related

SLE related

Wilson’s disease

32
Q

What are reversible causes of suspected dementia?

A
  • Normal pressure hydrocephalus
  • Hypothyroidism
  • Vitamin B12 deficiency
  • Neurosyphilis
  • Pseudodementia [depression]
33
Q

What is the triad of symptoms of normal pressure hydrocephalus?

A

Dementia

Ataxia

Urinary retention

34
Q

Which is not a core symptom of depression?

a] low energy

b] lack of interest in activities

c] feeling of worthlessness

A

c] feeling of worthlessness

35
Q

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

a] Months of year backwards - lack of attention= will get distracted halfway through

36
Q

Dementia and delirium table

Onset

Age

Course

Cause

Hallucinations/delusions?

Cognitive impairment?

> Inattention/distraction

Psychomotor symptoms

Consciousness?

Treatment

A

DPD 2020 (48 decks)

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