Lecture 14: Geriatric Psych Flashcards
1
Q
Important Considerations for Geriatric Psych (9)
A
- aging process
- Age related Disorders
- Medical/Psych/neurology
- cognitive changes
- frailty, mobility, special senses
- Drug effects and poly pharmacy
- interdisciplinary and interactive specialty: elder social service
- old-old or frail elders: special approach to medial care
- palliative approach
2
Q
Psychosocial consideration (4)
A
- phase of life issues
- retirement
- loss/grief
- empty nest
- grand-parenting - approaching mortality
- dependency
- functional decline
3
Q
Social Factors (4)
A
- loss of income
- dependence on social programs:
- medicare
- social security
- medicaid - assisted living and nursing home care
- isolation
4
Q
Dementia: Major and Mild neurologic disorder (5)
A
- Dementia/Major ND: syndrome of disabling, acquired loss of memory and intellect across multiple domains
- usually caused by a progressive loss of function
- typically involved progression loss of function
- ADLs - usually complicated by psychiatric and behavioral symptoms
- MCI/Mild ND
5
Q
Types of Dementia (5)
A
- Alzheimer’s Disease-most common
- vascular dementia: stroke, white matter disease
- Lewy Body Dementia/Parkinson’s disease
- Fronto-temporal dementia: FTD ex, pick’s disease
- Many others
- neurologic
- nutritional: B12, thiamine def.
- endocrine: hypothyroidism
- infectious: syphillis, HIV
- normal pressure hydrocephalus; involving CSF (tx shunting) - mixed dementia: more than one illness at work
- alcohol use, head trauma, etc.
6
Q
Alzheimer’s (8)
A
- early and late onset types
- early=before 65, familial
- late=after 65 - long prodromal period
- often preceded by mild cognitive impairment
- short-term memory loss
- ability to learn and retain new information
- episodic
- autobiographical memory - gradual progression over years, 6-10 years
- early, middle, late clinical stages
- evolving/overlapping definitions
- clinical symptoms vs. biomarkers (lab tests for definitive answer, not very useful, no great biomarker for alzheimer’s) - about 2/3 of dementias
7
Q
Alzheimer’s Diagnosis (4)
A
- current no specific definitive tests
- R/O other disorders
- R/I characteristic presentation and course
- use of rating scales
- MMSE
- MOCA: montreal cognitive assessment
- clock: good for tracking progress
- SLUMS
8
Q
Pathology Alzheimer’s (3)
A
- plaques and tangles
- amyloid and tau
- amblyoid, extracellular
- Tau intracellular - amyloid hypothesis
- that amyloid is the cause, not proven
9
Q
Alzheimer’s Loss of Function and ADLs (Activities for Daily Living) (6)
A
- instrumental ADLs lost first:
- driving: can make car work, but judgement is impaired
- using technology - basic ADL lost in 2nd and 3rd stages
- dressing
- bathing
- grooming
- toileting - incontinence
- loss chewing, swallowing, interest in food
- weight loss
- ataxia, falling
10
Q
Early/Mild Alzheimer’s Disease-stages (3)
A
- STM (short term memory) loss
- anxiety
- depression
11
Q
Middle/moderate Alzheimer’s(4)
A
- sleep problems
- psychosis
- agitation
- need for supervision
12
Q
Late/Severe Alzheimer’s (4)
A
- 24 hour a day care
- wandering
- yelling
- severe speech problems
13
Q
Vascular Dementia (4)
A
- multi-infarct dementia
- uneven progression, wax and wane is severity
- vascular lesions
- sub-cortical changes: white matter decrease
14
Q
Mild Neurocognitive Disorder (ND)
A
- cognitive decline, but not disabled
15
Q
Major neurocognitive disorder (ND)
A
- disabling cognitive decline
16
Q
Frontotemporal Dementia (6)
A
- Pick’s disease-tau inclusion bodies in frontal and temporal lobes
- “tauopathy”
- No amyloid - primary progressive aphasia
- changes in personality, executive function, judgement early in course
- speech and language problems
- progression to memory loss
17
Q
Lewy Body Dementia
A
- Overlaps with PD and sometimes AD
- fairly sudden onset
- Early psychosis-visual hallucination
- parkinsonian symptoms
- not well treated with parkinson’s treatment - fluctuation: derlium like symptoms
- often intolerant to antisychotics
18
Q
Lewy body
A
- a-synunclein (protein) intracellular inclusion
- diffuse or localized
19
Q
Parkinson’s Dementia (2)
A
- develops long agter motor symptoms
- loss of logic and reasoning
* falls under umbrella of lewy body dementia
20
Q
Behavioral and Psychiatric Symptoms of Dementia BPSD (9)
A
- speech and language changes
- circadian rhythm disturbance
- sundowning - inappropriate vocalization
- wandering
- shadowing: following caregiver
- agitation/aggression
- catastrophic reaction
- mood lability
- delusions: paranoia, other psychotic symptoms
21
Q
Dementia Treatment (2)
A
- cholinesterase inhibitors
- increase brains supply of acetylcholine
- supportive but not curative - Namenda: supportive, mostly mid to late disease
- blocks NMDA receptors, glutamate receptors
22
Q
Cholinesterase inhibitors (3)
A
- Aricept
- Razadyne
- Exelon
- increase brains supply of acetylcholine
23
Q
Psychiatric Medications in Dementia
A
- no specific psychiatric medication approved for dementia
- off-label use
- need for informed consent due to off-label use (from caregiver)
- commonly used
- antipsychotics (atypicals)
- mood stabilizers
- benzodiazepine
- SSRI < SNRI
- trasozone
24
Q
Common Off-label medications for dementia (6)
A
- antipsychotics (atypicals)
- mood stabilizers
- benzodiazepine
- SSRI < SNRI
- trasozone
25
Q
Controversial Use antipsychotics in dementia (4)
A
- black box warning by FDA due to increased morbidity and mortality
- limited efficacy
- lack good alternatives, may have to use antipsychotics
- individual patients may respond well
26
Q
Medications to BPSD (7)
A
- target symptom approach
- empirical, variable
- avoid polypharmacy
- low dose and duration
- avoid anticholinergics
- initially consider non=pharmacologic measures
- consider delirium and pain
27
Q
Delirium (3)
A
- cognitive disturbances usually related to systemic conditions
- illnesses
- drugs
- drug withdrawal - altered sensorium
- sensorium=senses in touch with reality - relatively short time course
28
Q
Rx factors for delirium (7)
A
- elders
- children
- CNS disorders
- previous episodes
- malnourished
- multiple organ system illness
29
Q
Delirium (5)
A
- cognitive fluctuation, confusion, psychosis, lucid intervals
- sleep/circadian rhythm disturbance
- agitated and withdrawn types
- comorbidity with dementia
- possible sequelae
30
Q
Derlium Treatment (5)
A
- adders underlying conditions
- normalize environment
- small doses antipsychotics
- limit benzodiazepines - protection from impaired judgement
- minimize restraints
31
Q
Goal psychiatric interview
A
- establish rapport, relationship
- understand their level of cognitive impairment
- do NOT patronize
- test memory using scale
- MOCA scale
- clock test - assess mood
- ask about suicidal thinking
- ask risk factors for suicide
- isolation, hopelessness, depression, chronic pain, hx of drug use, recent trip to doctor’s office
32
Q
Amnestic Disorder
A
- loss of memory due to medical condition or drug
- head injury
- nutrient deficient
33
Q
Bereavement exclusion
A
DMS 4 would hinder treatment 6 months after a significant death
-judgement call, should probably still treat patient
