Geriatric Psychiatry Flashcards
List risk factors for depression in the elderly
Female Theme of loss (spouse, home, health) Past history of depression Microvascular ischemic brain changes Personality disorder Medication condition - Stroke - Parkinson's - Dementia - Cardiac - Cancer - COPD
List some modifiable factors for depression in the elderly
Caregiver stress Alcohol Abuse Medications - Beta blockers - Benzodiazepines - Prednisone
What are some atypical features of depression in the elderly
Little mood feelings Loss of interest Increased anxiety Poor concentration and memory Negative outlook about self and world Somatic complaints Disability gap Psychotic feature
List the risk factors for suicide in the elderly
- have lower suicidal ideation but greater suicide completeness Older male severe depression previous suicide attempt alcohol abuse
List the 6 Ps of things that can affect sleep in the elderly
Pain Paroxysmal nocturnal dyspnea Pee (BPH, UTI, diuretic) Partner Pharmaceuticals Physical environment
Discuss the A,B,C,D,E presentation of dementia in the elderly
Activities of daily living affected
Behaviour and psychological symptoms of dementia
Cognitive impairement (amnesia, aphasia, apraxia, agnosia, disturbed executive functioning)
Depression
Effect on others, especially caregivers
List the behaviour and psychological symptoms of dementia
Apathy Depression Aggression Mania Agitation Psychosis
List the activities of daily living
DEATH
- Dressing/bathing
- Eating
- Ambulating
- Toileting
- Hygiene
List the instrumental activities of daily living
SHAFT
- Shopping
- Housekeeping
- Accounting
- Finances
- Food preparation
- Transportation
List the diagnostic criteria for a major neurocognitive disorder
Decline in >=1 cognitive domains as noted by
- concern of cognitive decline as noted by the individual, knowledgeable informant or children
- substantial impairment documented by standardized testing
- interference with independence of daily living (ADLs or iADLS)
- delirium or other medical condition ruled out
List the cognitive domains
- PALMES Perceptual motor Complex attention - sustained attention - divided attention - selective attention Language Learning and memory Executive function - planning - working memory - decision making Social cognition
List the markers for severity of dementia and treatment at each stage
Mild - MMSE >20 with loss of some ADL - improve cognition - slow progression Moderate - MMSE 10-20 loss of some ADLs - preserve ADLs - maintain safety while delaying institutionalization Severe - MMSE <10 loss of most ADLs requiring 24/7 care - manage behaviours
List the criteria for when a CT head is required for major neurocognitive disorder
Age <60 Rapid decline in cognition Head trauma Neurological symptoms Cancer Anticoagulants Incontinence Gait problems Atypical presentation
Discuss the epidemiology, pathophysiology and typical presentation of Alzheimer’s Dementia
Epidemiology
- Most common
- >65
- Female > Male
- 7-10 year prognosis
- most are sporadic but <10% due to familial
- Apo protein E genetic factor
Pathophysiology
- cortical atrophy and decreased hippocampus size
Presentation
- insidious onset and gradual progression
- progressive short term memory loss first
- decline in any cognitive domain
- limited insight
- apraxia and agnosia come later
Discuss the epidemiology, pathophysiology and typical presentation of vascular dementia
Epidemiology
- 2nd most common
- male > female
Pathophysiology
- subcortical vascular dementia with many vascular risk factors (arterial disease, diabetes, dyslipidemia, hypertension, smoking)
Presentation
- stepwise cognitive deterioration
- temporal relationship with cognitive decline and vascular event
- decline in memory, cognitive reasoning and executive dysfunction with subcortical deficits
- neuroimaging show cerebrovascular disease
Discuss the epidemiology, pathophysiology and typical presentation of Lewy Body Dementia
Epidemiology
- 3rd most common type
Presentation
- progressive memory loss with fluctuations in cognition, attention and alertness
- change in attention and learning rather than memory first
Diagnostic Features
- insidious and gradually progressive
- core features
- fluctuating cognition with pronounced variation in attention and alertness
- recurrent visual hallucinations
- spontaneous parkinsonism after onset of cognitive decline (Parkinson’s have dementia 5-10 years after onset of TRAP symptoms)
- suggestive features
- REM sleep behaviour disorder
- severe neuroleptic sensitivity
- probable if 2 core or 1 core and 1 suggestive
Discuss the epidemiology, pathophysiology and typical presentation of frontotemporal dementia
Epidemiology - male > female - 45-65 - gradual onset over 6-8 years Behaviour Variant Presentation - behavioural disinhibition - apathy or inertia - loss of sympathy - stereotype, compulsive behaviour - hyperorality - score well on cognitive tests Language Variant Presentation - prominent decline in language ability in form of speech production, word finding, object naming, or word comprehension
Discuss the epidemiology, pathophysiology and typical presentation of normal pressure hydrocephalus
Presentation - 3Bs
- Brain - cognitive impairement
- Balance - ataxic gait and difficulty maintaining balance
- Bladder - urinary incontinence
Investigations
- neuroimaging showing enlarged ventricles
Discuss cholinesterase inhibitors for dementia
- Donepezil (1st line), Rivastigmine Mechanism - stop breakdown of ACh to increase it in synapse Indication - Alzheimer's - Vascular - Lewy Body - Parkinson's Contraindication - heart block - frail Side Effects - nausea/vomiting - weight loss - sleep disturbance - bradycardia
Discuss NMDA antagonists for dementia
- Memantine (used if anticholinesterase have intolerable side effects) Mechanism - non-competitive inhibitor of NMDA to prevent excitatory cell death Indication - moderate to severe Alzheimer's Side effects - confusion - headache
List the SMART approach to managing behaviour and psychological symptoms of dementia
Safety Assessment
- remove patient from environment that may cause harm
Medical Assessment
- rule out pain, delirium, depression, medication, or other psychiatric condition
Assess competency
Rest and General Support
- hearing, vision support
Trial of medication
- mild agitation, aggression, psychosis SSRI (Celexa, Cipralex, Zoloft)
- severe agitation, aggressive, psychosis atypical antipsychotic
- depressive symptoms and anxiety cholinesterase/memantine then SSRI
- sleep disturbance trazadone, lorazepam
List the starting and maximum doses of medication for BPSD for atypical antipsychotics, typical antipsychotics and SSRIs
- atypical increase every 3-7 days Risperidone: 0.5-2 Olanzapine: 2.5-10 Aripriprazole: 2-10mg Quetiapine: 25-200 - typical increase every 3-7 weeks Haldol: 0.5-1.5 - SSRIs increase every 1-2 weeks Citalopram: 10-20 Escitalopram: 5-10 Sertraline: 25-100 - Sedatives increase ever 3-7 das Trazadone 25-100mg
Discuss the non-pharmacological therapy for BPSD
Behavioural intervention - redirection - distraction - supervision Elimination of trigger - no hearing aids - pain - sleep - medication One-to-one social contact
List the risk factors for delirium
Independent Risk Factors - Vision impairement - Severe illness - Cognitive impairement - High urea/creatinine Precipitants - Restraints - NPO status or malnutrition - Multiple new medications - Foley catheter - Iatrogenic event
Discuss the pathophysiology of delirium
Reduced cerebral Metabolism
- Failure of cholinergic transmission leading to hypoactive delirium
- Change in locus coruleus - noradrenergic system leading to hyperactive
Discuss the Confusion Assessment Method screening for delirium
- Acute onset of confusion that is change from patient’s normal mental status and has fluctuating course
- Presentation of inattention (easily distracted, serial 7s, WORLD backwards)
- disorganized thinking or altered level of consciousness
Discuss the differences in hypoactive and hyperactive delirium
Hyperactive
- hyperactive level of psychomotor activity accompanied with labile mood, agitation and uncooperativeness
Hypoactive
- hypoactive psychomotor activity with sluggishness and lethargy
- quiet, slow to respond to questions, decreased spontaneous movement
Mixed
- rapid fluctuations in delirium OR normal level of activity even though attention and awareness disturbed
Differentiate between depression and dementia
Onset
- subacute in depression vs insidious
Course
- rapid decline in depression vs slow in dementia
Mood
- consistently depressed vs labile in dementia
Interest
- cannot enjoy in depression
First presentation
- mood in depression vs cogntive decline in dementia
Language
- aphasia and word finding difficulties in dementia
History
- past history of mood disorder in depression
Differentiate between delirium and dementia
Onset - acute in delirium vs insidious Course - fluctuates in delirium vs stable slowly progressive Duration - hours to weeks in delirium Attention - obtunded or hypervigilant in delirium vs normal Orientation - impaired in both Thinking - disorganized in delirium vs impoverished in dementia Perception - hallucinations in delirium Sleep-wake - always disrupted in delirium Physical illness - acute cause in delirium
Discuss the brain lobes and their functions
Frontal Lobe (LIMP) - language - intelligence - motor function - personality Temporal Lobe (LAME) - language - affective component of speech - memory - emotion Parietal Lobe (VAST) - visual spatial processing - association areas - symbolic recognition - topographic sense
Discuss quick screening test for dementia
Quick
- 3-item recall where get >=2
- clock drawing at 10 after 1100
- naming as many animals in 1 minute with >=12 normal
Discuss the advantages, disadvantages, the test assessment areas and scoring of the MMSE
Advantages - standardized - easy to track changes Disadvantages - not diagnostic - biased towards verbal items - biased towards Alzheimer's detection Test - orientation - registration - attention and calculation - recall - langugae - spatial Scoring - >=25 normal - 20-24 mild - 10-19 moderate - <10 severe
Discuss the test assessment areas and scoring of the MoCA
Advantages - better for detecting mild cognitive deficits Disadvantages - MMSE better for moderate to severe dementia Test - orientation - registration and recal - attention - langugae function - spatial ability - abstraction Scoring - 26-30 normal - 20-25 mild cogntive impairement - 15-20 mild dementia - 10-15 moderate dementia - <10 severe dementia
Discuss the different test effects for each of the dementias
Alzheimer's - all are affected Vascular - depends on where the lesion is Lewy Body - deficits in attention - deficits in visual spatial ability - deficits in executive function Frontotemporal - spare temporal lobe so have better memory so good orientation and recall
