Old Age Flashcards
How many patients with Parkinsons develop depression
66%
How many patients with Parkinsons develop dementia
40%
How many patients develop delirium one week after a stroke
30-40%
How many people with chronic physical illness develop depression
20%
How much more common is depression in patients with chronic physical health problems?
2-3 times more common than gen pop
Which memory is often affected in alcohol related dementia
Autographical
Triad of normal pressure hydrocephalus
Gait ataxia
Dementia
Urinary incontinence
Prevalence of normal pressure hydrocephalus in the elderly
0.4%
What is the first sx in normal pressure hydrocephalus?
Gait disturbance
Investigation of NPH
CSF tap test - 40-50mp withdrawn by LP with assessment of gait and cognition before and afterwards
Risk factors for subdural haematoma
Post trauma Elderly after fall HI Cerebral atrophy Alcoholism Epilepsy Clotting disorders Anticoagulants
When and how does Huntingtons usually present?
40s - frontal dementia and movement disorder
Risk of alzheimers in first degree relatives with the disease
3-4 times compared to controls
15-19% compared with % in controls
Risk of dementia with age
1% aged 60
5% aged 65
40% aged 85
Doubles every 5 years
Risk factors for Alzheimers
Age Downs APO4 allele Female HI
Which memory tends to be affected in Alzheimers
Initially short term followed by long term
Common sx of Alzheimers
Short-term memory followed by long term memory impairment
Expressive and receptive dysphasia
Lexical anomia - word-finding difficulty
Apraxia
Psychiatric symptoms in Alzheimers
Delusions - 15%
Hallucinations - 10-15%
Depression - 20%
Symptoms in BPSD
Apathy - 59.6% Depression - 58.5% Irritability - 44.6% Anxiety - 44% Agitation - 41.5%
Average survival expectation for Akzhaimers
8 years
Limitations of MMSE
Subject to variation with age, socio-economic status and educational achievement
Weighted towards verbal performance
Cut off for MMSE
24/30
Medications for mild to moderate cognitive impairment in Alzheimers
Donepezil
Rivastigme
Galantamine
(Cholinesterase inhibitors)
SEs of Donepezil
Nausea, vomiting, diarrhoea, anorexia
Headaches, dizziness
Benefits of Rivastigmine
Can be given as patch
What is Memantine described as
Drug modifying drug as NMDA antagonist and can be neuroprotective, protections neurons from excessive amounts of glutamate
SEs of Memantine
Dizziness Headache Diarrhoea Fatigue Gastric pain
Medication for severe Alzheimers
Memantine
When are cholinesterase inhibitors contraindicated
Severe asthma
Severe conduction defects
Prevalence of psychosis in Alzheimers
30-50%
How many cases of dementia are due to Vascular
20%
What type of stroke is linked with cognitive impairment
Midbrain and thalamic strokes
What is Binswangers disease?
Progressive small vessel disease
Subcortical dementia with slow intellectual decline and generalised slowing.
Common sx in Binswangers
Short term memory difficulties
Disorientation
Gait disturbance and dysarthria
Depression
Risk factors for vascular dementia
Old age Hypertension IHD Smoking Alcohol Hyperlipidaemia AF FHx Valvular disease Coronary artery disease Coagulopathies
Characteristics of vascular dementia different to Alzheimers
Vascular more common in males, Alzheimers in female
Stepwise in Vascular compared to gradual progressive course in alzheimers
Focal neurological signs present
Insight retained in vascular, often lost in alzheimers
Mood symptoms uncommon compared to flattened or euphoric mood in alzheimers
Somatic complaints like headache and dizziness common in vascular, uncommon in alzheimers
How many cases of dementia are LBD?
15-20%
Core symptoms of LBD
Progressive cognitive decline to interfere with functioning (central)
Two of the following for probable diagnosis: fluctuating cognition with profound variations in attention and alertness, recurrent visual hallucinations which are detailed, spontaneous motor features of parkinsonism (70% of cases)
Supported features suggestive of LBD
Repeated falls due to autonomic dysfunction Syncope Transient disturbances of consciousness Neuroleptic sensitivity Systematized delusions Hallucinations in other modalities
Prevalence of paranoid delusions in LBD
65%
Prevalence of auditory hallucinations in LBD
20%
Prevalence of visual hallucinations in LBD
60-80%
Impact of antipsychotics on LBD
Worsen parkinonism sx
How many patients with LBD may experience life threatening adverse effects to antipsychotics
50%
Decline rate per year of parkinsonism sx in LBD
10% per year
Which memory is spared in LBD
Short term
Medications in LBD
Cholinesterase inhibitors can improve cognition, delusion and hallucinations but not licensed in UK
What causes dementia in parkinsons
Degeneration of subcortical structures - substantia nigra, caudate, putamen and globus pallidus
Symptoms of Parkinsons Dementia
Executive dysfunction - planning, reasoning
Apraxia
Dysphasia
SEs of Levodopa
Visual hallucinations (most common) with preserved insight Psychosis Anxiety Euphoria Mania Impulsive behaviour Delirium
Best antipsychotic in Parkinsons
Clozapine
Quetiapine
Risk factors for psychosis in Parkinsons
Older age Longer duration of illness Dementia Severity of illness Insomnia Use of dopamine agonists Polypharmacy
Difference between diagnosis in LBD and Parkinsons
o Lewy body dementia: If both motor symptoms and cognitive symptoms develop within 12
months, then it is conventional to give a diagnosis of Lewy body dementia.
o Parkinson’s disease dementia: If the parkinsonian symptoms have existed for more than 12
months before dementia develops then a diagnosis of Parkinson’s disease dementia is given
What scan can differentiate between Parkinsons and LDB
SPECT: greater caudate involvement in LBD
What can DAT help to differentiate?
LBD from Alzheimers - shows dopamine deficiency
What medication is licensed for treatment of parkinsons disease dementia?
Rivastigmine
Types of FTD
Picks
Primary progressive aphasia
Semantic dementia
Corticobasal degeneration
Age of onset of FTD
40-75
How many presenile cases of dementia are due to FTD
20%
Early clinical features of FTD
Personality change - disinhibited, social misconduct, lack of insight
Behaviour change - apathy, mutism, repetitive behaviour
Late features of FTD
Behavioural rigidity Impulsivity Emotional lability Fatuosness Executive dysfunction Hyperorality
Memory impairment in FTD
Affected later and not as seriously
Spatial orientation preserved
Symptoms in Picks
Emotional blunting Coarsening of social behaviour Disinhibition Apathy or restlessness Aphasia
Symptoms in primary progressive aphasia
Progressive decline in language with sparing of other cognitive deficits
Speech is non-fluent, mute in later stages
Symptoms in semantic dementia
Fluent speech but difficulties in word naming and meaning
Other cognitive domains preserved
How many patients with Picks have a positive FHx?
50%
Most common dementia in early onset (<65)?
Alzheimers
What sx are common in early onset Alzheimers?
Language and visuospatial
Sx in PSP
Balance difficulties Abrupt falls Slurred speech Dysphagia Agitated at times
Characteristic syndrome of PSP
ophthalmoplegia, pseudobulbar palsy, and axial dystonia
vertical gaze palsy
What is Bells phenomenon?
Reflexive upturning of eyes on forced closure of the eyelids
Eye signs in PSP
ophthalmoplegia
Loss of convergence and Bells phenomenon
Retraction of upper eyelids resulting in wide-eyed, unblinking stare
Sx of delirium
Rapid fluctuations over minutes and hours
Clouding of consciousness
Reduced attention and distracted
Global impairment in cognition with disorientation
Impairment of recent memory
Disturbance in sleep/wake cycle with nocturnal worsening of sx
Emotional lability
Visual hallucinations
Incoherent speech
Paranoid delusions
Prevalence of delirium in elderly on hospital
10-40%
Prevalence of delirium in gen pop
0.4%
Duration of delirium
Usually <1 week
Environmental and supportive measures for delirium
Education
Reorientation
Reassurance
Adequate lighting
Reduce unnecessary noise, Consistent staffing
Correct sensory impairment
Optimise patients condition with attention to hydration, nutrition, elimination and pain
Safe environment - remove objects which patient could harm self or others
NICE guidelines for medication in delirium
<1 week on Haloperidol or olanzapine
Benzo use in delirium
Can increase agitation and increase risk of falls and disinhibition
Helpful if delirium caused by withdrawal of alcohol or sedatives
Prevalence of depression in >65
10-15%
Prevalence of depression in residential and nursing homes
15-30%
Which physical health conditions are high risk of depression?
Cardiovascular disease
Cancer
CNS disorders - stroke, dementia
Risk of depression in dementia
25%
More common sx of depression in the elderly
Hypochondiacal and delusional Somatic concerns Poor subjective memory Apathy Poor motivation Anxiety/OCD-like Psychomotor sx
Risk factors for late life depression
Female
Poor health
Disability
Poor perceived social support
Trial period of antidepressant in elderly should last how long
2-3 months
Maintenance period of antidepressants in the elderly
2 years
How many elderly do not respond to antidepressants
30%
Recovery rate of elderly depression with ECT
80%
Which SEs more common in elderly with ECT
Confusion
Cognitive impairment
Prognosis of elderly depression
At 2 years 33% are we,, 33% remain depressed
Good prognostic factors for elderly depression
Onset less than 70 years old Short duration of illness Absent physical illness Good previous adjustment Good previous recovery
Poor prognostic factors for elderly depression
Severe life events during follow up period
Poor medication adherence
Severity of initial illness
Co-morbid physical illness
Presence of psychotic symptoms
Duration of illness for more than 2 years
3 or more previous episodes
Previous history of Dysthymia
Cerebrovascular disease (including vascular depression)
How many elderly patients with pseudodementia during depressive episodes go on to develop dementia
40% within 3 years
Mania accounts for how much of mood disorders in the elderly?
5-10%
One year prevalence of Bipolar in >65?
0.4% compared with 1.4% in younger adults
Average age of onset of elderly bipolar
55
M:F ratio of elderly bipolar
1:2
First line prophylaxis for elderly bipolar
Lithium
Prevalence of late onset psychosis in elderly in community
0.1-4%
Which gender more affected by late onset psychosis?
Remales
Clinical features of late onset psychosis
Paranoid delusions - 90% of patients
Auditory hallucinations - 70%
Visual hallucinations - 60%
Characteristics of late onset psychosis
o Fewer negative symptoms
o Better response to antipsychotics
o Better neuropsychological performance
o Greater likelihood of visual hallucinations
o A lesser likelihood of formal thought disorder
o A lesser likelihood of affective blunting
o A greater risk of developing Tardive dyskinesia (The risk of developing Tardive dyskinesia
with older antipsychotics is increased in older people by 5-6 times)
Risk factors for late onset psychosis
Sensory deprivation Social isolation Cognitive decline Polypharmacy Paranoid and schizoid personality Life events Female FHx - but weaker than early onset SCZ
Most common psychiatric disorder excluding dementia in elderly
Anxiety
Most prevalent anxiety disorder in elderly
Phobia
Common anxiety sx in elderly
Hypochondriacal
Depressive sx
Abuse of sedative drugs and alcohol
Most common cause of agoraphobia in the elderly
Physical illness
CI of Disulfiram
HTN
Cardiac failure
CVE
IHD
Risk factors for self-harm in the elderly
o Physical illness
o Widowhood and divorce or separation from a co-habitee
o Social isolation and loneliness
o Simply living alone
o Unresolved grief usually after death of a spouse is a commonly found risk factor for DSH.
Social RFs of suicide in the elderly
social isolation, lack of someone to confide in,
concerns over dependents or a move from home to residential care.
Prolonged grief reaction
Prevalence of PD in the elderly
5-10%
Which personality traits may intensify with age?
Depressive illness
Paranoid traits
Prevalence of inappropriate sexual behaviour in dementia
7%
18% in care homes
Interventions for sexually inappropriate behaviour in dementia
ABC system
When should treatment be initiated in bereavement?
Suicidal ideation
Severe functional impairment
Signs of severe depression
How many of the elderly develop depression needing treatment one year after bereavement of spouse?
10-20%
Phases of normal grief reaction
Phase 1 - Shock and protest – includes numbness, disbelief and acute
dysphoria
Phase 2 Preoccupation – includes yearning searching and anger
Phase 3 – disorganization – includes despair and acceptance of loss
Phase 4 – resolution
Duration of normal grief reaction
In normal grief reactions substantial improvement is expected within 2 months
to 6 months, and those who continue to meet criteria for major depression after
this time period should receive antidepressant or psychotherapy
What are the three types of abnormal grief?
Inhibited grief – absence of expected grief symptoms at any stage
Delayed grief – avoidance of painful symptoms within 2 weeks of loss
Chronic grief – continued significant grief related symptoms 6 months after
loss
