Memory Impairments: Dementia, Delirium And Old Age Psychiatry Flashcards

Question

What is the intervention for mild to moderate Alzheimer’s disease?

Answer 1

Acetylcholinesterase inhibitors ->Donepezil and rivastigmine

Answer 2

Memantine is recommended, which is a partial NMDA receptor antagonist that protects from glutamate-mediated excitotoxicity

Answer 3

Progressive dementia characterised by alpha-synuclein deposits in the neocortex, substantia nigra and hippocampus and there is associated neuronal loss. It is characterised by: -> Fluctuating cognition -> Visual hallucinations -> Parkinsonian features like bradykinesia, rigidity, **must start at the same time as cognitive symptoms.**

Answer 4

Sensitivity to antipsychotics Reduction in dopamine in SPECT imaging REM sleep disturbances Orthostatic hypotension, falls, syncope, and incontinence

Answer 5

Affects more men than women Age is 50-83 years old, with age of death being 68-92 years old

Answer 6

CT scan shows relative sparing of medial temporal lobe and deep white matter lesions Temporal lobe is relatively preserved Reduced levels of presynaptic dopamine transporter

Answer 7

Acetylcholinesterase inhibitors used for treatment of non-cognitive symptoms like apathy and agitation Avoid the use of antipsychotics which will worsen Parkinson’s symptoms

Answer 8

Second most common dementia, characterised by sudden stepwise deterioration due to small vessel disease which is typically caused by cerebral ischaemia, with deficits dependent on the affected region. It is associated with risks for cardiovascular disease and affects men more than women, typically those aged 60-70 years old.

Answer 9

Sudden stepwise progression Onset occurs often a stroke and has associated motor symptoms Impairments occur in emotions, personality an dlanauage Neurological impairments with rigidity, akinesia

Answer 10

-> Establish causative factors for disease -> Medication such as aspirin and anticoagulants ->Screening for cardiovascular disease factors such as cholesterol, clotting, vasculitis and autoimmune conditions like rheumatoid factor ->ECG, Carotid artery Doppler ultrasound and MRI ->Establish causative factors ->Promote lifestyle changes

Answer 11

Second most common dementia with an age of onset after 53 that causes degeneration of the the frontal and temporal lobe involving tau proteins and the DNA binding protein TDP-43. There is stereotypical and repetitive and compulsive behaviour. Memory and visuospatial functioning is preserved in the early stages. There is a significant family history and associated with autosomal dominant mutation.

Answer 12

Behavioural variant caused by intracellular accumulation of tuna protein to form Pick bodies, which causes a progressive deterioration of behaviour and cognitive symptoms which include: -> Disinhibition in food and sex, loss of social empathy, -> Preference for sweet food -> Compulsions and rituals -> Cognitive symptoms of poor attention and executive dysfunction with decisions -> Imaging will show assymetrical abnormalities of the contralateral temporal lobes

Answer 13

Disease of the temporal lobe affecting Wernicke’s area where there is fluent speech but impaired language function for meaning of words and finding words, and with disease progression behavioural variant dementia emerges.

Answer 14

Effortful speech that is non fluent, caused by atrophy in Broca’s area.

Answer 15

Fluent speech but loss of concept and meanings, and there is atrophy of the left temporal lobe over the right temporal lobe

Answer 16

Occupational therapy Physiotherapist Speech and language therapy Structured daily routine

Answer 17

Abbreviated Mental Test score (AMTS) is a 10-point test for rapidly assessing elderly patients for the possibility of dementia.

Answer 18

A fluctuating disturbance of consciousness, global impairment of cognitive function and perception which develops acutely and is associated with behavioural abnormalities such as a disturbed sleep-wake cycle.

Answer 19

Most common acute disorder in hospitals affecting in patients. Tends to affect high risk groups such as: Elderly Pre-existing dementia Blind/deaf patients Post-operative patients, especially cardiac Burn victims Alcohol and Benzodiazepine dependent

Answer 20

Those aged over 65 years old Pre-existing cognitive impairment Current hip fracture Existing severe illness that is at risk of deterioration

Answer 21

Prolonged surgery with a high risk of intraoperative trauma and blood loss that may induce hypoxia in brain cells.

Answer 22

Stroke patients Critical care patients Hip fracture Vascular surgery Poly pharmacy Renal impairment Immobile patients

Answer 23

Acute onset but gradual resolution of symptoms, that is slower in the elderly. Patchy amnesia may occur and there is a high risk of mortality and development of dementia.

Answer 24

Global impairment of cognition and attention with disorientation in recent memory ->Psychomotor agitation ->Visual or auditory hallucinations -> Changes in mood and behaviour ->Paranoid delusions ->Rambling or incoherent speech -?Sleep deprivation and nocturnal worsening of symptoms, which is a modifiable risk factor for prevention of delirium

Answer 25

Lethargic Reduced mobility Reduced appetite Loss of interest in activities Quiet and withdrawn

Answer 26

Multi factorial and includes: -> Infective -> Metabolic -> Intracranial -> Endocrine

Answer 27

UTI Chest infection Abscess Endocarditis Subacute bacterial endocarditis

Answer 28

Electrolyte disturbances, especially Ca2+ and Mg2+ Hepatic encephalopathy due to buildup of toxins Uraemia Cardiac failure Hypothermia

Answer 29

Raised intracranial pressure from: Head injury Encephalitis Metastatic tumour

Answer 30

Vitamin deficiencies of B12, folate, B3 and B2 Diabetes Hypoglycaemia Disease of adrenal gland, pituitary, thyroid and parathyroid

Answer 31

Diuretics Antihypertensives Anticonvulsants Digoxin NSAIDs Hypoxia

Answer 32

Take history from patient and any family/carer for behaviour, drug use, oral intake and precipitating factors Examine drug history since hospital admission Check patient vital signs e.g blood pressure, heart rate, blood glucose and temperature General multi-system examination Focused investigation such as urinalysis, blood tests, sputum culture, thyroid function, chest x-ray

Answer 33

Identify and treat underlying cause Ensure effective communication and reorientation De-escalation for distressed patients and if necessary, low dose short treatment with haloperidol

Answer 34

Avoid sedation unless necessary to mitigate risk to patient and help facilitate investigation and treatment Antipsychotics should ideally be atypical quetiapine and avoid typical like haloperidol at the lowest possible dose Reduce unnecessary noise in the environment Antipsychotics in the elderly increase the risk of cardiac and neurological side effects

Answer 35

Provide environmental and supportive measures Create a stimulating environment with lighting, reducing unnecessary noise, correcting sensory impairment and mobilising patients Optimise patient for hydration, nutrition, urination and pain control

Answer 36

-> Severe psychomotor retardation and agitation -> Cognitive impairment, especially with effortful tasks -> Cotard’s syndrome, where they believe they do not exist, dead and are rotting -> Depressive delusions about poverty and physical illness that are nihilistic in nature Patient may present with somatic, anxiety or hypochondriacal complaints. First line treatment is SSRIs at a low starting dose with gradual increases. For severe illness, ECT is reccomended as it does not present as a contraindication with dementia

Answer 37

Exaggerated symptoms Depressed mood with previous history of sepsis on Low effort on relatively easy tasks Effective response to anti-depressant medication

Answer 38

Commonly associated with depression, neurotic personality and existing psychiatric illness. Persistent thoughts/behaviours associated with the somatic symptom which generates a high level of anxiety

Answer 39

Patients in this group are less likely to report classical symptoms and this presents as: Insomnia Palpitations Irritability Loss of appetite Fatigue Muscle tension

Answer 40

Older people are more likely to engage with poly pharmacy due to co-morbidity which increases the risk of side effects and drug interactions and associated physiological changes so lower dose is required: ->There is an **increased free drug levels and half life** due to reduced body mass and lower albumin. ->There is reduced blood flow to the liver reducing drug metabolism ->There is reduced renal clearance that prolongs the cumulative effects of drugs and risk of toxicity -> There is a reduced drug absorption due to lower gastric pH and mesenteric blood flow and motility

Answer 41

Reduction of -> Cholinergic receptors in the brain -> Dopapminergic cells in the basal ganglia -> Noradrenaline levels -> Increased sensitivity to sedatives due to fewer receptors

Answer 42

Primary care services such as GPs, health visitors and community nurses Specialised old age psychiatry units Outpatient mental health units or psychiatric day hospitals Community psychiatric nurses that assess patients on referral from GPs and home support Informal carers Voluntary organisations such as charities Residential and nursing care provided by local authorities such as nursing homes

Answer 43

Mental capacity should always be presumed in adults regardless of indivudal factors like dementia diagnosis. However it is important to assess the patient’s capacity for a specific procedure and to make personal welfare decisions. The patient’s capacity should be based on their ability to understand the information relevant, weigh it up, retain the memory and communicate their choice. The presence of a psychiatric illness should be evaluated for the influence on their decision. Finally, it is important to gather information about the patient’s views when they had capacity or if they have a relative wit surrogate decision-making.