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SUMGERI > GERI-DDD > Flashcards

GERI-DDD Flashcards

1
Q

What are some important issues we have to deal with around mental health and aging?

A
  • cognitive loss
  • psychological diseases of old age
  • psychosocial issues of the elderly
  • medial legal issues (MDM capacity, DPOA)
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2
Q

Is confusion inherent to ONLY aging?

A

Not necessarily, no!
ITS a symptom!
DDX1. dementia 2. delirium 3. depression *the three D’s

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3
Q

How is confusion variable?

A
  • constant vs intermittent
  • acute vs chronic
  • differs from symptoms of mental illness in younger people
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4
Q

Do we get new cases of schizophrenia in elderly pts?

A

NOPE!

PROBLEM IS we give- antipsychotic which can make confusion worse

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5
Q

What is the hallmark of dementia?

A

MC LOSS OF RECENT MEMORY

  • insidious onset
  • impaired judgment
  • behavioral issues (sleep disturbance, aggression/agitation-coping)
  • early vs late issues
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6
Q

What diseases CAUSE dementia?

A 
Alzheimer's disease (70%) 
multi-infarct 
Lewy Body 
HIV
frontal-temporal
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7
Q

What diseases are ASSOCIATED with dementia?

A

Parkinson’s disease B12 deficiency Thyroid disease Liver disease

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8
Q

Probably criteria to diagnose dementia

A
  • clinical exam r/o others
  • mental status evaluation
  • deficits in >2 cognitive areas
  • progressive decline
  • normal level of consciousness
  • onset between 40-90yrs
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9
Q

Is there a specific test we can do to diagnose dementia?

A

No,

CLINICAL diagnosis

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10
Q

What is the last thing that happens clinically when you reach a state of dementia with Alzheimers?

A

functional decline

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11
Q

What is the progression of brain changes and clinical manifestations in Alzheimers?

A

Amyloid plaques –> neurofibrillary tangles –> brain cell loss –> memory loss –> functional decline
Brain changes occur w/o CP

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12
Q

What are the risks for Alzheimers disease?

A

Nonmodifiable: age, family hx, APOE-4 gene, Downs syndrome

Modifiable: head trauma, HTN, DM, smoking, depression

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13
Q

How does age affect your risk for Alzheimer’s?

A

-prevalence of AD doubles q 5yrs >60
-85yo has 50% risk of AD
-2x parents w/ AD, 1st degree relative w/ AD: risk is double that of general population = 54%
risk by 80yo

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14
Q

What are probable criteria that can lead you to making a diagnosis of Alzheimer’s Disease?

A
  • no other cause
  • supportive factors: + family hx, cerebral atrophy, normal EEG, normal lumbar puncture
  • clinical criteria + histopathology
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15
Q

What happens in early Alzheimer’s Disease?

A
  • gradual memory loss
  • preserved level of consciousness
  • impaired ADLs
  • subtle language errors
  • impaired spatial perception
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16
Q

What happens in late Alzheimer’s Disease?

A
  • aphasia: no speaking
  • apraxia: no purposeful actions
  • agnosia: no recognizing/interpreting
  • inattention
  • left-right confusion
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17
Q

Agnosia, aphasia and apraxia are shared with other dementias - what would lead you to think that this is specifically Alzheimer’s?

A

WORD FINDING ISSUES! apathy/indifference delusion disorientation

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18
Q

What is Lewy Body Dementia? How does it present?

A
  • mild Parkinsonism symptoms shaking, tremor, gait
  • unexplained falls
  • visual hallucinations
  • fluctuating cognition
  • extreme sensitivity to antipsychotic meds
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19
Q

What does a diagnosis of Lewy Body dementia require clinically/symptom-wise to be confirmed?

A
  • *a diagnosis requires a progressive decline in your ability to think, as well as two of the following:
  • fluctuating alertness and thinking (cognitive) function
  • repeated visual hallucinations
  • Parkinsonian symptoms
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20
Q

What is frontotemporal dementia? How does it present?

A
  • onset before 60
  • language disarray
  • profound personality changes -behavioral issues(impulsive, hypersexual
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21
Q

What are the types of frontotemporal dementias?

A
  • Progressive Supranuclear Palsy: PSP a degenerative disease of specific regions of the brain
  • Primary Progressive Aphasia: language slowly impaired, not other mental functions
  • Semantic Dementia: loss of word meaning
  • ALS w/ Dementia: Amytrophic lateral sclerosis neurodegenerative dz
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22
Q

What is vascular dementia? How does it present?

A

-stepwise deterioration 2/2 ischemic events –> can be small and transient -TIA, lunar infarcts, focal infarcts or they can be massive; every time there’s an event, there’s a stepwise decline in function/cognition

  • normal level of consciousness
  • functional loss may correlate w/ cerebrovascular events (CT/MRI)
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23
Q

What are the types of vascular dementia?

A

cortical, subcortical, white matter lesions, mixed or specific

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24
Q

What categories of dementia will have changes show up on imaging?

A

Vascular dementia –> cortical/subcortical infarcts, white matter lesions
Frontotemporal dementia –> marked atrophy in frontal and/or temporal lobes

**Lewy Body and Parkinson’s dementias don’t have remarkable imaging

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25
Q

What are the strengths/limit for the MMSE?

A

PROs-standardized, widely used

  • reproducible validity
  • quickly administered
  • useful scoring

CON-does not test executive function

  • not correlative w/ capacity
  • screening tool
  • education dependent
  • not culturally valid
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26
Q

What does the Montreal Cognitive Assessment (MoCA) test for?

A
  • more executive function testing

- visuospatial/executive -naming -memory -attention -language -abstraction -delayed recall -orientation

27
Q

Treatment and management for dementia

A
  • NO TX treat dementia but there ways to slow it down
  • education of pt and family
  • Rx
  • develop strategy for caregiver respite
  • long-term care planning
  • facilitate environmental success
  • stimulate cognitive function w/ challenges
  • promote feelings of pleasure
  • don’t force it (easy to get frustrated)
28
Q

What are some general strategies to help protect cognitive function?

A
  • treatment of vascular risk factors- HTN)
  • neuroprotection- diet, moderate EtOH
  • building up neuronal reserves -cognitive activity, physical activity, social & leisure
29
Q

What is the efficacy for cholinesterase inhibitors?

A

low efficacy –> most of them don’t show a real benefit past 6 months
they can help slow cognitive decline in someone w/ dementia
Wait b4 prescribing

30
Q

What is delirium? How does it present?

A
  • acute onset , stress causing metabolic changes
  • waxing and waning course
  • common in the hospital
  • memory, orientation, perception, sleep, speech, consciousness and psychomotor hypo and hyperactive or mixed changes,
31
Q

What is the differential diagnosis for delirium?

A

VAST! -medications

  • infection -
  • surgery
  • dehydration
  • laboratory abnormalities
  • associated w/ other disease, cancer, collagen vascular disease, MI, dementia, depression
32
Q

What is the prevalence of delirium among hospitalized older adults?

A

11-41% (hospitalized for medical illness) 40-52% (postop hip fracture) 10-39% (postop noncardiac surgery) 13-44% (postop cardiac surgery)

33
Q

Why is delirium so dangerous, especially in the hospital?

A

SYPMTOM
marked increase in mortality rate -
-treat the underlying problem

34
Q

Assessment for delirium

A
  • vitals
  • PE to diagnose infectious process or other acute medical conditions -UTI
  • Cr, Na, K, Ca, glucose
  • CBC w/ diff
  • review old and new anticholinergic meds, sedating meds -review the need for foley, IVs, etc.
35
Q

When would be an appropriate time to use a benzodiazepine in an elderly pt?

A

AVOID just bc delirisus
if the pt is agitated, not responding to a sitter, and safety is an issue while being treated for a reversible medical condition

36
Q

Why are benzodiazepines and other anticholinergic drugs so dangerous in elderly pts?

A 
because of their side effects! 
-hot as a hare 
-dry as a bone 
-blind as a bat 
-red as a beet -
mad as a hatter
** benzos can also cause rebound anxiety
37
Q

Drugs w/ mild anticholinergic activity (important ones)

A 
bupropion 
chlorthalidone 
codeine 
diazepam 
digoxin 
fentanl 
furosemide f
luvoxamine
38
Q

Drugs w/ moderate anticholinergic activity

A

carbamazepine

amantadine

39
Q

Drugs /w high anticholinergic activity

A

amitriptyline
clozapine
doxepin
diphenhydramine

40
Q

Which medication classes should you check to see if your pt is on if they develop delirium?

A
  • *KEY meds to cause delirium!
  • narcotics
  • benzodiazepines
  • anticholinergics
  • antipsychotics
41
Q

What percentage of elders experience depression?

A

40% often do not recognize or acknowledge their depression –> elderly males at highest suicide risk

42
Q

Symptoms of depression

A

Sleep - increased or decreased (early morning awakening) Interest - decreased
Guilt/worthlessness
Energy - decreased or fatigued
Concentration/difficulty making decisions
Appetite and/or weight increase or decrease
Psychomotor activity - increased or decreased
Suicidal ideation

43
Q

What are risk factors for depression?

A

-chronic medical illness
-loss of a loved one
-relocation -
diability

44
Q

How are elderly pts more likely to present with depression?

A

more likely to have somatic complaints or hypochondriasis

45
Q

What diseases are closely linked to depression?

A
  • Parkinson’s disease
  • Alzheimer’s disease
  • stroke *s/p stroke - increased likelihood for major/minor depression
46
Q

What are common symptoms of depression?

A

-loss of energy and enthusiasm -sleep change: early morning awakening -weight loss -anxiety and perplexing

47
Q

What is the Ddx for depression?

A
  • hypo/hyperthyroidism
  • vitamin deficiency B12, D, folate
  • anemia
  • infection
  • UTI
48
Q

How can we distinguish between delirium and depression based on presentation?

A

delirium: AMS/encephalopathy
- fluctuating consciousness,
impaired cognitive testing depression:
“pseudodementia”
- appears demented but performs well on cognitive testing

49
Q

How can we distinguish between delirium and depression based on signs and symptoms?

A

delirium: acute/subacute onset,
fluctuating,
sleep-wake disruption,
often reversible

depression: gives up easily on cognitive tests, “i don’t know”,
poor eye-contact, flat affect,
cries easily

50
Q

How can we distinguish between delirium and depression based on time course?

A

delirium: occur in a person w/ dementia
depression: abruptly, often w/ major stressor

51
Q

How can we distinguish between delirium and depression based on prognosis?

A

delirium: may “predict” dementia- postop delirium
depression: independent risk factor for dementia

52
Q

How can we diagnose depression?

A

PHQ-2- lack of interest, depression mood? yes to both is 83% sensitive!

PHQ-9

53
Q

How do we treat depression?

A

-medication (SSRIs)
-counseling
-education
CBT PST (problem solving therapy) TIP (treatment initiation and participation) ECT (electroconvulsant therapy)

54
Q

What medications are useful to treat depression?

A
  1. SSRI - primary treatment, risk of serotonin syndrome
  2. SNRI - better for neuropathic pain (e.g. Remeron) **check Na in 2 wks if on other rx that affect ADH -diuretics, NSAIDs, monitor for GIB/NSAID/ASA
  3. Buproprion - no sexual SE, no weight gain, no GIB
  4. TCAs - anticholinergic, increase HR, orthostasis, monitor EKG!
55
Q

What can both SSRIs and SNRIs cause?

A

hyponatremia due to SIADH

OTHER DDX HYPO

56
Q

What are other major mental health issues that the elderly encounter?

A
  • loneliness
  • boredom
  • vulnerability
  • impaired self-assessment skills
  • loss: home, loved ones, respect of the community -substance abuse -EtOH abuse
57
Q

What is the relationship between elderly pts and EtOH?

A
  • 5.6% binge drinking in the last month

- 2 million elders have alcohol issues -high risk drinkers: 15% men, 12% women -stressful life events may be triggers

58
Q

How can we screen for alcohol use in elderly pts?

A

Ask!!Screening: CAGE-C: cut down A: annoyed G: guilty E: eye-opener

Lab: -gamma-glutamyl transpeptidase (GGT) enzyme in liver that indicates liver dz

  • mean corpuscular volume (MCV) –> suggestive of folate/B12 deficiency
  • carbohydrate-deficient transferring (CST) 4-5 EtOH proportion of transfer w/ fewer chains increased
59
Q

What are some end of life issues we deal with when working w/ elderly pts?

A
  • recognition of time limitations
  • hearing bad news
  • accepting bad news
  • preparing for death
60
Q

What is capacity?

A

-MDM capacity w/ DPOA medical decision making capacity - can make a decision about their own trajectory of care

61
Q

What are the guidelines for determining capacity?

A
  • cognitive status (level of dementia, delirious?)
  • understand problem and its consequences
  • risks vs benefits of treatments
62
Q

Assessment of capacity

A

age

  • physical health
  • ADLs
  • mental and emotional health
  • substance abuse
  • acceptance of services
  • financial resources
  • environment
  • orientation
63
Q

Does the client understand….

A
  • the situation?
  • the potential consequences of the situation
  • their own limitations in the situation and the alternatives available?

SUMGERI (14 decks)

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