Mood Disorders / Dementia

Question 1

What is the defintion of “mood”?

Answer 1

mood is a person’s predominant feeling at a given time

an individual’s mood may not be apparent to an outside observer

(i.e. may appear to be happy when the mood has been low for prolonged time periods)

Question 2

What is the definition of affect?

Answer 2

affect involves moment-to-moment changes in the emotional state

and the external expression of these feelings as observed by the examiner

(e.g. if you feel sad, you might cry and then other people know how you are feeling)

Question 3

How can the season and weather analogy be used to compare mood and affect?

Answer 3

• mood is like the season
• over the course of a season, you expect to see a certain type of weather
  
  • e.g. in winter, it is cold and rains a lot
• affect is like the weather
• on a certain day in a particular season, the weather might not fit with the weather pattern expected for that season
  
  • e.g. there might be a day in winter that is very dry and sunny
• mood is the underlying predominant feeling that a person has, however their affect can change day-to-day and might not mirror the mood

Question 4

What is meant by “euthymia”?

Answer 4

• mood can be measured on a spectrum
• euthymia describes the middle ground state of mood, where someone is not experiencing signs of mania or depression
• there is a reference range of normality (i.e. euthymia)
  
  • feeling happy or sad comes within the normal range of mood changes

Question 5

What is meant by “hypomania”?

Answer 5

• a mood state or energy level that is elevated above normal, but not so extreme as to cause impairment
• it is a state of elated mood that persists for at least 4 days
  
  • it usually lasts for around 7 days
• it does not meet the criteria to be described as a manic episode

Question 6

What is meant by “dysthymia” or “subthreshold depression”?

How long does someone have to have this for to be diagnosed?

Answer 6

• a persistent low mood state that does not recover into the euthymic threshold
• it does not quite meet the criteria for depression
• an individual must be experiencing this low mood for at least 2 years to be described as dysthymic

Question 7

What are the biological, psychological and social impacts on mood?

Answer 7

Biological:

• chronic illness
• acute illness - pain and injury

Psychological:

• loss of function
• loss of role
• historical trauma (not necessarily physical) and how the individual perceives this trauma

Social:

• isolation
• loneliness

Question 8

What is the fundamental disturbance associated with mood disorders?

What additional symptom is this usually associated with?

Answer 8

• the fundamental disturbance is a change in the affect or mood to depression (with or without associated anxiety) or to elation
• mood change is usually accompanied by a change in the overall level of activity
  • most other symptoms are secondary to, or easily understood in the context of, the change in mood or activity

Question 9

What usually can bring on a mood disorder?

Answer 9

• most mood disorders tend to be recurrent
• the onset of individual episodes is often related to stressful events or situations
• sometimes there is no explanation at all as to why someone is living with a mood disorder

Question 10

What are described as the core symptoms of depression?

Answer 10

• reduced mood
• reduced energy / activity
• reduced interests (anhedonia)
• problems with concentration
• reduced self-esteem and self-confidence

Question 11

What is meant by anhedonia?

Answer 11

the inability to feel pleasure in normally pleasurable activities

the person no longer gets enjoyment from things that they previously liked to do

Question 12

What are other essential symptoms of depression that it is important to recognise?

Answer 12

• loss of enjoyment in daily activities
• tiredness and poor sleep
• appetite changes and weight loss
• loss of sex drive
• early-morning wakening
• diurnal variation in mood
• feelings of guilt, worthlessness & hopelessness

Question 13

What is meant by diurnal variation of mood?

Answer 13

• this describes how mood changes over the course of the day
• typically, an individual wakes up feeling down and starts to feel a bit better by late afternoon / early evening
• they may wake up feeling better and feel low by the end of the day

Question 14

What is meant by early-morning wakening as a symptom of depression?

Answer 14

• for a sustained period (at least 2 weeks) an individual wakes up at least 2 hours earlier than they usually would
• once awake, they cannot get back to sleep again

Question 15

Which group of disorders does depression belong to?

What other conditions fall in this category?

Answer 15

• depression is a form of affective mood disorder
• other examples include anxiety and bipolar disorder
• the symptoms of these conditions are often similar and there is considerable overlap
  
  • the diagnosis is determined by the actual combination of symptoms that individual has

Question 16

What condition does the term “depression” typically refer to?

Is this always a chronic condition?

Answer 16

• depression generally refers to major depressive disorder
• some patients may have depressed mood but not meet the DSM-V criteria for the diagnosis of major depression
  
  • these people may have minor depression
  • or if a recent event has precipitated the depression, this is adjustment disorder with depressed mood
• depression can occur as a single episode, or as an ongoing condition with periods of “relapse” and “remission”

Question 17

What factors are implicated in the aetiology of major depression?

Answer 17

• genetic susceptibility
• lifestyle factors including social situation
• alcohol / drug dependence
• abuse (sexual, physical, emotional) - particularly in childhood
• being unemployed
• previous psychiatric diagnosis
• diagnosis of a chronic disease
• lack of a confiding relationship
• post-natal depression
• living in an urban area

Question 18

What are 3 possible differentials for low mood?

Answer 18

• hypothyroidism
• bipolar affective disorder
• cancer / other terminal diagnosis

Question 19

What investigations need to be performed when someone presents with low mood for the first time?

Answer 19

• FBC
• U&Es
• haemotinics - folate, B12 and ferritin
  
  • to look for signs of anaemia
• LFTs
  
  • ​to look for alcohol / drugs / cancer
• CXR
  
  • ​to look for chronic infection (e.g. TB)
• ECG
  
  • ​to look for metabolic disturbances
• full comprehensive history and mental state examination

Question 20

What criteria is used to diagnose depression?

Answer 20

the DSM-V diagnostic criteria for major depression

diagnosing depression requires a relatively short history of at least 2 weeks

Question 21

How is the DSM-V criteria used to identify symptoms that are present in major depression?

Which ones are essential?

Answer 21

at least FIVE of the criteria must be present almost every day for the last 2 weeks

ONE and TWO are essential

• depressed mood
• loss of interest or pleasure in previously enjoyed activities
• changes in weight (>5% in 1 month) OR change in appetite
• changes in sleep - insomnia or hypersomnia
• psychomotor agitation (e.g. symptoms of anxiety)
• fatigue or low energy
• feelings of guilt or worthlessness
• reduced concentration or decisiveness
• suicidal ideation or attempt

Question 22

According to DSM-V, what 4 other features MUST all be present to diagnose depression?

Answer 22

• symptoms cause significant distress or impair functioning
• symptoms are not due to medication, other substance or underlying illness
• symptoms are not better explained by a schizophrenia spectrum disorder or psychotic disorder
• no history of a manic or hypomanic episode
  
  • if this is present, consider bipolar affective disorder

Question 23

What other symptoms may be present in depression, but are not necessary for diagnosis?

Answer 23

• psychotic symptoms - especially in severe depression
• hallucinations
• delusions

Question 24

What are the 3 core symptoms associated with major depression?

Answer 24

• low mood
• anhedonia
  
  • does not take pleasure from activities that were previously enjoyable
  • often withdraws from social activities
• low energy levels
• these must be experienced for at least part of the day on every day for the last 2 weeks

Question 25

What are the cognitive symptoms of minor depression?

Answer 25

• feelings of guilt, uselessness, worthlessness
• thoughts of suicide
  
  • always ask about suicidal thoughts and whether these thoughts have been acted upon (e.g. stock up on paracetamol)
• poor concentration

Question 26

What are the functional symptoms of minor depression?

Answer 26

• changes in sleep
• weight loss or weight gain - a change of >5% is significant
  
  • ensure to ask whether weight loss / gain is intentional
• loss of libido
• memory problems
• psychomotor retardation
• agitiation / fidgeting

Question 27

What sleep disturbances may be experienced by someone with depression?

Answer 27

• difficulty getting to sleep
• waking up several times during the night
• early waking

Question 28

Why might someone with depression lose or gain weight?

Answer 28

• they may gain weight through “comfort eating”
• they may lose weight as they no longer take pleasure in eating and / or feel nauseous so eat less

Question 29

What is meant by pyschomotor retardation?

Answer 29

• the patient can be very “slow” with both their thoughts and actions, to a degree that is noticeable by others

Question 30

Why might someone with depression complain of memory problems?

Answer 30

• there is likely to be no issue with their memory
• if you test them on their memory, you may notice that they do not concentrate when information is first given to them
• this means that the information is not processed, and so they are not able to recall it
• it is the information processing, and not the memory recall, that is at fault

Question 31

What other clinical characteristics are associated with depression that are not present in all patients?

Answer 31

• diurnal variation of symptoms
• hallucinations and delusions
  
  • if present, these are generally congruent to the current mood
• Schneider’s positive symptoms can occur in severe depression
  
  • ​these are usually associated with schizophrenia
• melancholia - the patient feels unable to experience any emotions at all

Question 32

What are the 6 most important questions to ask when taking a history of someone with depression?

Answer 32

• Have you felt low or miserable recently?
• Do you feel like you have lost your emotions?
• Does it happen / do you feel like this everyday?
• Has anything happened recently that you think might have triggered this?
• Have you lost interest in things you usually enjoy?
  
  • ​Do you still see your friends regularly?
• Does your current mood / experience interfere with your normal life?
  
  • ​sleep
  • weight loss
  • feelings of guilt / worthlessness

Question 33

When performing a mental state examination, what might you notice about a person with depression’s appearance, behaviour and speech?

Answer 33

Appearance & behaviour:

• poor self care
• lack of eye contact
• does not “engage” in conversation
• little movement OR lots of fidgeting

Speech:

• monotone
• hesitant
• slow

Question 34

What mnemonic can be used to remember all the things to include in a depression history?

Answer 34

DEAD SWAMP

• D - depressions
• E - energy levels
• A - anhednia
• D - death
  
  • this includes thoughts about suicide and self-harm
• S - sleep pattern
• W - worthlessness / guilt
• A - appetite
• M - mentation
  
  • ​this includes the ability to make decisions and concentrate
• P - psychomotor agitation / retardation

Question 35

What mnemonic can be used to perform a suicidal risk assessment within the depression history?

Answer 35

SLAMPS

• S - suicidal thoughts
• L - lethality
  
  • e.g. are they planning on taking 10 paracetamol or jumping off a cliff?
• A - a suicide plan
  
  • ​do they have a current plan about how / when they would kill themselves?
• ​M - means
  
  • ​do they have access to firearms / dangerous equipment?
  • what medication do they have at home?
• P - past history
  
  • ​have they tried to commit suicide before?
  • how did they do this?
• S - suicide of a family member or peer

Question 36

What are the possible psychological interventions that can be offered in depression?

Answer 36

• lifestyle factors that are known to improve mood
  
  • e.g. social interaction, regular exercise, healthy diet
• cognitive behavioural therapy
  
  • either in person or online

Question 37

What are the other treatment options available in depression?

Answer 37

• antidepressant medication therapy
  
  • typically used in conjunction with psychological interventions
  • needs regular follow-ups to review effectiveness of treatment
• electroconvulsive therapy (ECT)
  
  • ​reserved for most severe cases in an inpatient setting

Question 38

How does treatment change based on severity of depression diagnosis?

Answer 38

*

Question 39

What happens in cognitive behavioural therapy?

Answer 39

• this is a type of “talking therapy” which helps the patient to:
• have a better understanding of their symptoms
• recognise negative thought patterns, and how to better manage these thoughts
• encourage new ways of positive thinking

Question 40

What very important question needs to be asked to rule out a certain condition before prescribing antidepressants?

Answer 40

• need to ask about possible periods of mania or hypomania before prescribing to ensure it is not a case of bipolar disorder presenting with a low mood episode
• antidepressants can WORSEN bipolar disorder
  • they should be treated with mood stabilisers, such as lithium

Question 41

What is the aim of antidepressant therapy?

How long should they initially be given for?

Answer 41

• the aim of treatment is to induce remission
• assess the effectiveness of antidepressants at 6-8 weeks
  
  • if no benefit is felt by 6 weeks, the current drug is likely to be unsuitable for the patient
  • consider alternative medication
• antidepressants are roughly as equally effective in treating depression as CBT / psychological interventions
  
  • ​they may be more effective in treating severe depression

Question 42

What type of antidepressant is first line in treating depression?

What should be done if this treatment is not effective?

Answer 42

selective serotonin reuptake inhibitors (SSRIs)

• e.g. fluoxetine, citalopram, sertraline, paroxetine
• need to allow 4 - 6 weeks before beneficial effects may be seen
• if one SSRI is not effective, attempt another SSRI before trying other drugs

Question 43

What are the potential side effects of SSRIs?

Answer 43

• nausea and vomiting
• abdominal pain
• sexual dysfunction
• patients may have increased suicidal thoughts during the first few weeks of taking these before improvement is seen

Question 44

If SSRIs are ineffective, what medications may be considered?

How long should medication be trialled for?

Answer 44

• serotonin-noradrenaline reuptake inhibitors (SNRI)
  
  • e.g. venlafaxine
  • may be superior to SSRI in severe depression
• tricyclic antidepressants
• monoamine oxidase inhibitors (MAOIs)
• need to trial medications for at least 4-6 weeks to see if they are effective
• if medication is not effective, try another drug in the same class before trying a different class

Question 45

What must someone have in order to be diagnosed with bipolar effective disorder?

Answer 45

• 2 or more episodes where mood and activity are significantly disturbed
• 1 episode MUST be elation / elevation of mood and increased energy or activity (mania / hypomania)
• or it could be a depressive episode
• (someone with 2 discrete episodes of depression does not necessarily have bipolar disorder - must be at least 1 episode of elation)*

Question 46

What is bipolar affective disorder?

Answer 46

it is a psychiatric condition that involves both depressive and manic episodes

this is different to depression, as there is no mania in depression

in bipolar disorder, it is possible for mania to occur at any time, or when under antidepressant medication

Question 47

What is the difference between bipolar 1 and bipolar 2 disorder?

Answer 47

Bipolar 1 disorder:

• there is underlying depression interspersed with episodes of mania
• usually depressive and manic episodes occur in the ratio 1:1

Bipolar 2 disorder:

• the depression is more predominant
• the ratio of depressive to manic episodes is about 5:1
• manic episodes may only be slight (i.e. hypomania) or precipitated by antidepressant medication

Question 48

Who tends to be affected by bipolar disorder?

When is it usually diagnosed and how does it present?

Answer 48

• it is more common in women and usually starts in teenage years
• first incidence is usually before the age of 30
• first presentation can involve any / all of: depression, hypomania, mania
  
  • many cases of bipolar that present with a depressive episode are diagnosed and treated as depression
  • may not be truly diagnosed as bipolar disorder for many years

Question 49

What is meant by “rapid cycling bipolar” and why is it important to identify?

Answer 49

• there are > 4 episodes a year of mania + depression
• the person quickly swings from a low phase to a high phase without having a period of “normal” in between
• the treatment is different from other types of bipolar disorder

Question 50

What genetic factors are implicated in the aetiology of bipolar disorder?

Answer 50

• 5-10% increased risk if a family member has depression / bipolar
• increased risk in those with a tendency to have rapid mood changes (cyclothymia) or unusual periods of elated feelings (hyperthymia)

Question 51

What are the different factors that can precipitate an event in bipolar disorder?

What factors can cause rapid cycling mood in patients with bipolar disorder?

Answer 51

• life factors that lead to early morning waking can precipitate a manic episode
  
  • e.g. working shift patterns, one off event where you have to wake early
• positive life events can precipitate mania
• negative life events can precipitate mania and depression (more likely)
• pregnancy, cerebrovascular accident (or anything affecting frontal lobe / cortical structures), steroids and stimulants can precipitate mania
• thyroid disease, antidepressants, steroids, alcohol and cannabis can cause rapid cycling mood

Question 52

In general, what is the main difference between mania and hypomania?

Answer 52

• they are both forms of elated mood
• mania is an elated mood lasting 1-2 weeks (or more) with psychotic symptoms, that affects social functioning
• hypomania has no psychotic symptoms and does not last as long (>4 days)

Question 53

What are the typical clinical features of someone with bipolar affective disorder?

Answer 53

• elated mood
  
  • this can be mania or hypomania
• irritable mood
• feelings of increased self worth
• inappropriate social behaviour, including compulsive actions
• general increase in activity
  
  • ​this includes a lack of sleep
• heighten sense of one’s abilities / prestige
• delusions and hallucinations
• very fast speech
• altered perceptions
  
  • ​e.g. they may perceive colours as brighter, or sounds as louder

Question 54

What is meant by irritable mood and labile mood in bipolar disorder?

Answer 54

• irritable mood occurs between periods of elation, and is often expressed as inappropriate anger
• the general mood in mania is very variable, with periods of elation lasting anywhere between minutes and days
  • this variable mood is known as labile mood

Question 55

What type of inappropriate social behaviour is seen in bipolar disorder?

Answer 55

• this may include sexual behaviour
• it often includes compulsive actions such as gambling, spending lots of money, dangerous driving

Question 56

What features are typically seen when someone has a general increase in activity in bipolar disorder?

Answer 56

• lack of sleep as patients feel they only need a couple of hours of sleep
• they will often switch from one activity to another, without finishing any of them

this is known as distractability and shows poor attention and concentration

Question 57

What are 3 very important questions to ask when taking a bipolar history?

Answer 57

• Have you ever felt especially happy or cheerful?
  
  • ​How long does it last for?
  • How often does it occur?
• Do you feel like you lose your temper more easily than usual?
• Do you feel like you have more energy than usual?

If the patient answers “yes” to any of these questions, then ask about:

• sleeping patterns
• restlessness
• opinion of the self
• libido (v increased)
• spending habits

Question 58

What might be observed on a mental state examination of someone with bipolar disorder?

Answer 58

Appearance:

• bright coloured clothes / eccentric

Behaviour:

• overly friendly, perhaps inappropriate

Speech:

• fast and difficult to interrupt

Mood:

• elated / irritable

Thought:

• fast
• sentences may be logical, but linked by puns and similar sounding words, and not by ideas
• patient may be very self important

Perception:

• hallucinations - usually occur with elated mood

Cognition:

• distractability

Question 59

How is bipolar disorder diagnosed based on the DSM-V criteria?

Answer 59

• diagnosis typically based on mania:
• elated or irritable mood for at least one week, PLUS at least 3 of:
  
  • inflated self esteem
  • decreased need for sleep
  • accelerated speech
  • racing thoughts / flight of ideas
  • distractability (reported or observed)
  • increased goal directed activity or psychomotor agitations
  • excessive activity
• impaired social or occupational functioning
• episode is not due to substance misuse or other organic cause

Question 60

What are the potential differential diagnoses for bipolar disorder?

Answer 60

• unipolar (regular) depression
• schizophrenia
• borderline personality disorder
  
  • can mimic cycling moods of bipolar
  • bipolar tends to be episodix, BPD tends to be chronic
• organic causes of mania

Question 61

What are common endocrine, neurological and drug organic causes of mania?

Answer 61

Endocrine:

• thyroid, pituitary or adrenal disorders

Neurological:

• MS
• cerebrovascular accident (CVA)
• epilepsy
• tumour - particularly those that affect the frontal and subcortical areas

Drugs:

• steroids
• stimulants
• antidepressants

Question 62

What factors increase the risk in bipolar disorder?

What might the appropriate course of action be?

Answer 62

• reckless behaviour
• aggression
• promiscuous sexual behaviour (STIs, pregnancy)
• lack of self care (can be a big risk e.g. in diabetes)
• some patients may need to be sectioned for inpatient care
  
  • particularly as during manic episodes, patients feel “very healthy”

Question 63

What investigations are performed to diagnose bipolar disorder?

Answer 63

• there are no diagnostic tests for bipolar disorder and diagnosis is clinical
• some blood tests are performed to rule out an organic cause at first presentation:
  • FBC
  • U&Es
  • LFTs
  • TFTs
  • urinary drug screen

Question 64

What chemicals / hormones might be raised in bipolar disorder?

Answer 64

• there are increased serotonin and noradrenaline levels during episodes of mania
• inositol phosphate is increased in mania
  
  • this is a chemical that increases the metabolism of lithium
• there is increased cortisol release / response to stress in mania

Question 65

What sign on neuroimaging is associated with poor prognosis in bipolar disorder?

Answer 65

white matter hyperintensities

• the presence of these is related to poor prognosis, increased frequency of manic episodes and cognitive impairment

Question 66

What is the first and second-line management for an acute manic episode?

Answer 66

FIRST LINE:

• an atypical antipsychotic
  
  • e.g. olanzapine, risperidone, clozapine
• be weary of agranulocytosis (low WCC)

SECOND LINE:

• valporate, iamotrigine (anticonvulsant) or lithium

Question 67

What is involved in the management of bipolar disorder during a depressive episode?

Answer 67

• AVOID ANTIDEPRESSANTS
  
  • these can cause rapid cycling mood
• try an atypical antipsychotic, such as olanzapine
• if this does not work, try adding lamotrigine (anticonvulsant) or possible lithium adjunct

Question 68

What is involved in the general maintenance management in bipolar disorder?

Answer 68

• try to avoid acute changes in medication regimens
• consider a mood diary, where patient rates their mood /10 everyday before going to bed
• consider education / therapy to encourage a proper diurnal pattern
• first line treatment is lithium - a mood stabiliser
• in case of manic or depressive episodes, first add an atypical antipyschotic
  
  • if response is poor then consider anticonvulsants

Question 69

What questions need to be asked about risk in mood disorders?

Answer 69

• risks to self
• risks to others
• risks of treatment
• risks of lack of treatment

risk to others includes risk of neglect to dependents e.g. young children

Question 70

What is meant by psychosis?

What can cause it?

Answer 70

• psychosis is a condition that affects the way your brain processes information
• it is a symptom, not an illness
• it causes you to lose touch with reality
• you might see, hear or believe things that are not real
• it can be caused by a mental or physical illness, substance abuse, extreme stress or trauma

Question 71

What are the 3 main symptoms associated with a psychotic episode?

Answer 71

• hallucinations
• delusions
• confused and disturbed thoughts

Question 72

What is the difference between a hallucination and a delusion?

Answer 72

Hallucination:

• this is where someone sees, hears, smells, tastes or feels things that do not exist outside their mind

Delusions:

• this is where someone has an unshakeable belief in something untrue
• the person is often unaware that their delusions or hallucinations are not real, which can cause them to become frightened or distressed

Question 73

What are the 3 major signs of disturbed, confused and disrupted patterns of thought?

Answer 73

• rapid and constant speech
• disturbed speech
  
  • e.g. switching from one topic to another mid-sentence
• a sudden loss in their train of thought, resulting in an abrupt pause in conversation or activity

Question 74

What is the definition of thought?

Answer 74

the act of thinking about or considering something, an idea or opinion, or a set of ideas about a particular subject

Question 75

What happens during normal thought form?

What happens if there is a thought disorder?

Answer 75

• topics of speech normally fluctuate as different ideas enter consciousness
• these topics are usually well-connected and speech is logical and organised
• thought disorder occurs when there is a problem in the way the content is linked together and delivered

Question 76

What questions should you consider when evaluating whether someone might have a thought disorder?

Answer 76

• How smoothly do the ideas flow from one to another?
• Are questions repeated and rephrased?
• Is conversation direct and informative or confusing and vague?
• (often you will leave the conversation feeling very confused, whilst the person with the disorder will not)*

Question 77

What are the 5 most common disorders of thought content?

Answer 77

• pre-occupations
  
  • e.g. “did I lock the back door?”
  • repeatedly thinking about this throughout the day, but it does not affect day-to-day living
• phobias
  
  • ​this is a concern, fear or worry that is outside normal range
  • for most people, it has no significant impact on life
• overvalued ideas
  
  • ​an individual spends more time thinking about one particular idea than others
  • e.g. always thinking about something that you don’t want to think / worry about
  • generally can push this idea aside for long enough to focus on other tasks
• obsessions
  
  • ​often starts small and grows large to a point that the person cannot control it / push it out of their mind
• delusions
  
  • ​fixed, firm false belief that is outside of that person’s cultural context

Question 78

How might someone tell you that they have a thought problem?

Answer 78

• beliefs that are not true
• sensing things that nobody else can
• saying that they have strange thoughts that are not their own
• feeling confused

Question 79

What is meant by a paranoid delusion?

Answer 79

• this involves intense and irrational mistrust or suspiscion that people are “out to get” the patient
• they become paranoid that people are talking about them, monitoring them and hunting them down

Question 80

What is meant by a grandiose delusion?

Answer 80

• the person has an over-inflated sense of worth, power, knowledge, or identity
• they believe they have a great talent or have made a great discovery
• e.g. “I am the King of Mars”

Question 81

What is meant by a nihilistic delusion?

Answer 81

• this is when the patient believes that they are dead and someone else is controlling their body
• it is often coupled with the hallucination of being able to smell rotting flesh
• this is seen in untreated severe depression in older adults

Question 82

What is meant by passivity phenomenon?

Answer 82

• this is the belief that an external agency is taking control over the person
• they believe that they have no control over their body or their actions
• this often leads to unpredictable and high risk behaviour around other people

Question 83

What is the definition of a delusion?

Answer 83

a fixed, unshakeable belief, despite evidence to the contrary, not held by others in the same culture

and held with intense personal conviction and certainty

Question 84

What are examples of sensing things that nobody else can?

Answer 84

• hearing things
• seeing people / animals
• something crawling under the skin
• strange taste
• odd smell
• feeling like an internal organ is painful

Question 85

What is the definition of a hallucination?

What are the 6 different types of hallucination?

Answer 85

a perceptual experience without an object or stimulus that appears subjectively real

• auditory - hearing something
• gustatory - tasting something
• visual - seeing something
• tactile - feeling something
• olfactory - smelling something
• somatic - internal organ pain

Question 86

What is the difference between an illusion and a hallucination?

Answer 86

• an illusion occurs when the brain tries to make sense of an existing stimulus
  
  • e.g. seeing screaming faces in the peppers
  • there is a true visual stimulus, but the brain misinterprets the information
• a hallucination occurs when there is no stimulus to excite the sensory organ

Question 87

What is the defintion of a thought disorder?

What first-rank symptoms of schizophrenia may be present in a thought disorder?

Answer 87

an abnormality in the mechanism of thinking such that to the observer the person doesn’t make much sense

first-rank symptoms of schizophrenia:

• thought withdrawal
• thought insertion
• thought broadcast

Question 88

What is meant by thought withdrawal?

Answer 88

• this occurs when the patient believes that thoughts are being taken out of their mind
• as a result, other people can read the thought that has been taken

Question 89

What is meant by thought insertion?

Answer 89

• the patient believes that thoughts are being put into their mind by other people
• they believe these thoughts are not theirs
• this can sometimes be physically painful

Question 90

What is meant by thought broadcasting?

Answer 90

• the patient believes that they are like an antennae that is broadcasting their thoughts
• they believe that everyone around them can pick up and understand their thoughts

Question 91

In mental health, who is considered to be an older adult?

Answer 91

• in many hospitals, you become an older adult > 80
• in mental health, you become an older adult > 65

Question 92

What is meant by the “stages of development” in >65s and what impact does this have on mental health?

Answer 92

• maturity occurs at 65+ years
• the conflict is thinking about whether they have lived a good life and the despair that life is coming to an end
• the event involves reflection on holding these 2 competing thoughts in their mind at the same time

Question 93

What are the 5 key factors that affect the mental health and wellbeing of older adults?

Answer 93

• discrimination
  
  • ​this includes discrimination by gender, ethnicity and AGE
• participation in meaningful activities
  
  • ​e.g. such as learning new skills, expanding their knowledge
• relationships
• physical health
• poverty
  
  • ​this is universal and affects younger people too

Question 94

What does the DEMENTIA mnemonic stand for when remembering causes of confusion in older people?

Answer 94

• D - drugs / delirium
• E - emotions / depression
• M - metabolic disorders
• E - eye and ear impairment
• N - nutritional disorders
• T - tumours, toxins, trauma
• I - infections
• A - alcohol, arteriosclerosis

Question 95

What are the 5 stages involved in assessing confusion in an older adult?

Answer 95

• taking a full, comprehensive history
• collateral history
  
  • this involves another person’s versions of events to determine whether confusion is new
• mental state examination (MSE)
• formulation
• cognitive screen

Question 96

What is the definition of delirium?

Answer 96

an acute onset syndrome with disturbances in attention, awareness and cognition

Question 97

Why is it very important to recognise delirium in hospitalised older adults?

Answer 97

• mortality is twice as high in a patient with delirium - no matter what condition they are in hospital for
• someone with delirium is 8 times more likely to develop dementia

Question 98

What are the possible causes of delirium?

Answer 98

• acute illness
• trauma
• surgery
• restraint
• length of stay
• moving environment
• malnutrition
• dehydration
• constipation
• co-morbidity
• medication (use of or the absence of)
• drugs
• alcohol (intoxication and withdrawal)
• polypharmacy

Question 99

What type of condition is dementia?

What features of behaviour are altered in this condition?

Answer 99

• it is a progressive neurodegenerative condition
• there is disturbance of multiple higher cortical functions
  
  • this includes a decline in memory & ability to learn new things
• accompanied by deteroriation in:
  
  • ​judgement and thinking
  • processing of information
  • emotional control, social behaviour or motivation

Question 100

What 3 things must be present alongside symptoms that are necessary for a diagnosis of dementia?

Answer 100

there are cognitive and behavioural symptoms that:

• interfere with work and social activities and
• represent a decline in prior levels of functioning and performing and
• are not explained by delirium or a major psychiatric disorder

Question 101

What is meant by Kitwood’s enriched model of dementia?

Answer 101

dementia = NI + H + B + P + SP

• NI - neurological impairment
• H - health & physical fitness
• B - biography, life history
• P - personality
• SP - social pyschology

if all 5 areas are impacted at the same time over 6 months (or more) then this is dementia

Question 102

What are the most common risk factors for Alzheimer’s dementia (the most common form of dementia)?

Answer 102

Modifiable risk factors:

• lifestyle risk factors
  
  • obesity, alcohol, smoking and other CVS risk factors
• social interaction
  
  • ​people who are able to interact in social settings in a way they find enjoyable

Non-modifiable risk factors:

• advancing age
• genetic predisposition (including trisomy 21)

it does NOT mean that if you follow all the guidance and have none of these risk factors, you will NOT develop dementia

Question 103

what are the 5 As associated with Alzheimer’s dementia?

Answer 103

Amnesia

• a form of memory loss
  
  • usually retain knowledge of their own identity and motor skills

Apraxia

• the individual has problems with motor planning to perform tasks or movements when asked
  
  • provided that the request or command is understood and the individual is willing to perform the task

Aphasia

• the inability to comprehend or formulate language

Agnosia

• the loss of ability to recognise faces, objects, places, smells or voices
  
  • usually only one sensory pathway is implicated

Associated behaviours

Question 104

How can Alzheimer’s dementia be recognised on CT scan?

Answer 104

• it is a disease of the brain that results in a loss of brain volume
• it looks as though the ventricles have increased in size, but they have not
• the brain tissue around this area has shrunk, meaning the ventricles fill the space left by atrophied brain tissue

Question 105

What are the 5 different features involved in the pathology of Alzheimer’s dementia?

Answer 105

• cerebral atrophy (loss of brain volume)
  
  • this is seen in the medial temporal lobes first
• this is due to deposition of senile plaques
• which are made from incorrectly folded amyloid protein
• TAO protein kills cells in the brain, leading to neuro-fibrillary tangles
• levels of acetylcholine in the brain are reduced
  
  • ​fewer neurotransmitters available means reduced ability of circuits in the brain related to cognition to work effectively