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Psychiatry > Geriatric Psychiatry > Flashcards

Geriatric Psychiatry Flashcards

1
Q

List risk factors for depression in the elderly

A 
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
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2
Q

List some modifiable factors for depression in the elderly

A 
Caregiver stress
Alcohol Abuse
Medications
- Beta blockers
- Benzodiazepines
- Prednisone
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3
Q

What are some atypical features of depression in the elderly

A 
Little mood feelings
Loss of interest
Increased anxiety
Poor concentration and memory
Negative outlook about self and world
Somatic complaints
Disability gap
Psychotic feature
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4
Q

List the risk factors for suicide in the elderly

A 
- have lower suicidal ideation but greater suicide completeness
Older male
severe depression
previous suicide attempt
alcohol abuse
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5
Q

List the 6 Ps of things that can affect sleep in the elderly

A 
Pain
Paroxysmal nocturnal dyspnea
Pee (BPH, UTI, diuretic)
Partner
Pharmaceuticals
Physical environment
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6
Q

Discuss the A,B,C,D,E presentation of dementia in the elderly

A

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

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7
Q

List the behaviour and psychological symptoms of dementia

A 
Apathy
Depression
Aggression
Mania
Agitation
Psychosis
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8
Q

List the activities of daily living

A

DEATH

  • Dressing/bathing
  • Eating
  • Ambulating
  • Toileting
  • Hygiene
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9
Q

List the instrumental activities of daily living

A

SHAFT

  • Shopping
  • Housekeeping
  • Accounting
  • Finances
  • Food preparation
  • Transportation
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10
Q

List the diagnostic criteria for a major neurocognitive disorder

A

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
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11
Q

List the cognitive domains

A 
- PALMES
Perceptual motor
Complex attention
- sustained attention
- divided attention
- selective attention
Language
Learning and memory
Executive function
- planning
- working memory
- decision making
Social cognition
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12
Q

List the markers for severity of dementia and treatment at each stage

A 
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
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13
Q

List the criteria for when a CT head is required for major neurocognitive disorder

A 
Age <60
Rapid decline in cognition
Head trauma
Neurological symptoms
Cancer
Anticoagulants
Incontinence
Gait problems
Atypical presentation
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14
Q

Discuss the epidemiology, pathophysiology and typical presentation of Alzheimer’s Dementia

A

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

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15
Q

Discuss the epidemiology, pathophysiology and typical presentation of vascular dementia

A

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

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16
Q

Discuss the epidemiology, pathophysiology and typical presentation of Lewy Body Dementia

A

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

17
Q

Discuss the epidemiology, pathophysiology and typical presentation of frontotemporal dementia

A 
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
18
Q

Discuss the epidemiology, pathophysiology and typical presentation of normal pressure hydrocephalus

A

Presentation - 3Bs
- Brain - cognitive impairement
- Balance - ataxic gait and difficulty maintaining balance
- Bladder - urinary incontinence
Investigations
- neuroimaging showing enlarged ventricles

19
Q

Discuss cholinesterase inhibitors for dementia

A 
- 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
20
Q

Discuss NMDA antagonists for dementia

A 
- 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
21
Q

List the SMART approach to managing behaviour and psychological symptoms of dementia

A

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

22
Q

List the starting and maximum doses of medication for BPSD for atypical antipsychotics, typical antipsychotics and SSRIs

A 
- 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
23
Q

Discuss the non-pharmacological therapy for BPSD

A 
Behavioural intervention
- redirection
- distraction
- supervision
Elimination of trigger
- no hearing aids
- pain
- sleep
- medication
One-to-one social contact
24
Q

List the risk factors for delirium

A 
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
25
Q

Discuss the pathophysiology of delirium

A

Reduced cerebral Metabolism

  • Failure of cholinergic transmission leading to hypoactive delirium
  • Change in locus coruleus - noradrenergic system leading to hyperactive
26
Q

Discuss the Confusion Assessment Method screening for delirium

A
  • 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
27
Q

Discuss the differences in hypoactive and hyperactive delirium

A

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

28
Q

Differentiate between depression and dementia

A

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

29
Q

Differentiate between delirium and dementia

A 
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
30
Q

Discuss the brain lobes and their functions

A 
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
31
Q

Discuss quick screening test for dementia

A

Quick

  • 3-item recall where get >=2
  • clock drawing at 10 after 1100
  • naming as many animals in 1 minute with >=12 normal
32
Q

Discuss the advantages, disadvantages, the test assessment areas and scoring of the MMSE

A 
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
33
Q

Discuss the test assessment areas and scoring of the MoCA

A 
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
34
Q

Discuss the different test effects for each of the dementias

A 
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

Psychiatry (15 decks)

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