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Old Age Flashcards

1
Q

How many patients with Parkinsons develop depression

A

66%

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2
Q

How many patients with Parkinsons develop dementia

A

40%

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3
Q

How many patients develop delirium one week after a stroke

A

30-40%

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4
Q

How many people with chronic physical illness develop depression

A

20%

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5
Q

How much more common is depression in patients with chronic physical health problems?

A

2-3 times more common than gen pop

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6
Q

Which memory is often affected in alcohol related dementia

A

Autographical

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7
Q

Triad of normal pressure hydrocephalus

A

Gait ataxia
Dementia
Urinary incontinence

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8
Q

Prevalence of normal pressure hydrocephalus in the elderly

A

0.4%

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9
Q

What is the first sx in normal pressure hydrocephalus?

A

Gait disturbance

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10
Q

Investigation of NPH

A

CSF tap test - 40-50mp withdrawn by LP with assessment of gait and cognition before and afterwards

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11
Q

Risk factors for subdural haematoma

A 
Post trauma
Elderly after fall
HI
Cerebral atrophy
Alcoholism
Epilepsy
Clotting disorders
Anticoagulants
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12
Q

When and how does Huntingtons usually present?

A

40s - frontal dementia and movement disorder

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13
Q

Risk of alzheimers in first degree relatives with the disease

A

3-4 times compared to controls

15-19% compared with % in controls

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14
Q

Risk of dementia with age

A

1% aged 60
5% aged 65
40% aged 85
Doubles every 5 years

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15
Q

Risk factors for Alzheimers

A 
Age
Downs
APO4 allele
Female
HI
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16
Q

Which memory tends to be affected in Alzheimers

A

Initially short term followed by long term

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17
Q

Common sx of Alzheimers

A

Short-term memory followed by long term memory impairment
Expressive and receptive dysphasia
Lexical anomia - word-finding difficulty
Apraxia

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18
Q

Psychiatric symptoms in Alzheimers

A

Delusions - 15%
Hallucinations - 10-15%
Depression - 20%

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19
Q

Symptoms in BPSD

A 
Apathy - 59.6%
Depression - 58.5%
Irritability - 44.6%
Anxiety - 44%
Agitation - 41.5%
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20
Q

Average survival expectation for Akzhaimers

A

8 years

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21
Q

Limitations of MMSE

A

Subject to variation with age, socio-economic status and educational achievement
Weighted towards verbal performance

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22
Q

Cut off for MMSE

A

24/30

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23
Q

Medications for mild to moderate cognitive impairment in Alzheimers

A

Donepezil
Rivastigme
Galantamine
(Cholinesterase inhibitors)

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24
Q

SEs of Donepezil

A

Nausea, vomiting, diarrhoea, anorexia

Headaches, dizziness

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25
Benefits of Rivastigmine
Can be given as patch
26
What is Memantine described as
Drug modifying drug as NMDA antagonist and can be neuroprotective, protections neurons from excessive amounts of glutamate
27
SEs of Memantine
``` Dizziness Headache Diarrhoea Fatigue Gastric pain ```
28
Medication for severe Alzheimers
Memantine
29
When are cholinesterase inhibitors contraindicated
Severe asthma | Severe conduction defects
30
Prevalence of psychosis in Alzheimers
30-50%
31
How many cases of dementia are due to Vascular
20%
32
What type of stroke is linked with cognitive impairment
Midbrain and thalamic strokes
33
What is Binswangers disease?
Progressive small vessel disease | Subcortical dementia with slow intellectual decline and generalised slowing.
34
Common sx in Binswangers
Short term memory difficulties Disorientation Gait disturbance and dysarthria Depression
35
Risk factors for vascular dementia
``` Old age Hypertension IHD Smoking Alcohol Hyperlipidaemia AF FHx Valvular disease Coronary artery disease Coagulopathies ```
36
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
37
How many cases of dementia are LBD?
15-20%
38
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)
39
Supported features suggestive of LBD
``` Repeated falls due to autonomic dysfunction Syncope Transient disturbances of consciousness Neuroleptic sensitivity Systematized delusions Hallucinations in other modalities ```
40
Prevalence of paranoid delusions in LBD
65%
41
Prevalence of auditory hallucinations in LBD
20%
42
Prevalence of visual hallucinations in LBD
60-80%
43
Impact of antipsychotics on LBD
Worsen parkinonism sx
44
How many patients with LBD may experience life threatening adverse effects to antipsychotics
50%
45
Decline rate per year of parkinsonism sx in LBD
10% per year
46
Which memory is spared in LBD
Short term
47
Medications in LBD
Cholinesterase inhibitors can improve cognition, delusion and hallucinations but not licensed in UK
48
What causes dementia in parkinsons
Degeneration of subcortical structures - substantia nigra, caudate, putamen and globus pallidus
49
Symptoms of Parkinsons Dementia
Executive dysfunction - planning, reasoning Apraxia Dysphasia
50
SEs of Levodopa
``` Visual hallucinations (most common) with preserved insight Psychosis Anxiety Euphoria Mania Impulsive behaviour Delirium ```
51
Best antipsychotic in Parkinsons
Clozapine | Quetiapine
52
Risk factors for psychosis in Parkinsons
``` Older age Longer duration of illness Dementia Severity of illness Insomnia Use of dopamine agonists Polypharmacy ```
53
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
54
What scan can differentiate between Parkinsons and LDB
SPECT: greater caudate involvement in LBD
55
What can DAT help to differentiate?
LBD from Alzheimers - shows dopamine deficiency
56
What medication is licensed for treatment of parkinsons disease dementia?
Rivastigmine
57
Types of FTD
Picks Primary progressive aphasia Semantic dementia Corticobasal degeneration
58
Age of onset of FTD
40-75
59
How many presenile cases of dementia are due to FTD
20%
60
Early clinical features of FTD
Personality change - disinhibited, social misconduct, lack of insight Behaviour change - apathy, mutism, repetitive behaviour
61
Late features of FTD
``` Behavioural rigidity Impulsivity Emotional lability Fatuosness Executive dysfunction Hyperorality ```
62
Memory impairment in FTD
Affected later and not as seriously | Spatial orientation preserved
63
Symptoms in Picks
``` Emotional blunting Coarsening of social behaviour Disinhibition Apathy or restlessness Aphasia ```
64
Symptoms in primary progressive aphasia
Progressive decline in language with sparing of other cognitive deficits Speech is non-fluent, mute in later stages
65
Symptoms in semantic dementia
Fluent speech but difficulties in word naming and meaning | Other cognitive domains preserved
66
How many patients with Picks have a positive FHx?
50%
67
Most common dementia in early onset (<65)?
Alzheimers
68
What sx are common in early onset Alzheimers?
Language and visuospatial
69
Sx in PSP
``` Balance difficulties Abrupt falls Slurred speech Dysphagia Agitated at times ```
70
Characteristic syndrome of PSP
ophthalmoplegia, pseudobulbar palsy, and axial dystonia | vertical gaze palsy
71
What is Bells phenomenon?
Reflexive upturning of eyes on forced closure of the eyelids
72
Eye signs in PSP
ophthalmoplegia Loss of convergence and Bells phenomenon Retraction of upper eyelids resulting in wide-eyed, unblinking stare
73
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
74
Prevalence of delirium in elderly on hospital
10-40%
75
Prevalence of delirium in gen pop
0.4%
76
Duration of delirium
Usually <1 week
77
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
78
NICE guidelines for medication in delirium
<1 week on Haloperidol or olanzapine
79
Benzo use in delirium
Can increase agitation and increase risk of falls and disinhibition Helpful if delirium caused by withdrawal of alcohol or sedatives
80
Prevalence of depression in >65
10-15%
81
Prevalence of depression in residential and nursing homes
15-30%
82
Which physical health conditions are high risk of depression?
Cardiovascular disease Cancer CNS disorders - stroke, dementia
83
Risk of depression in dementia
25%
84
More common sx of depression in the elderly
``` Hypochondiacal and delusional Somatic concerns Poor subjective memory Apathy Poor motivation Anxiety/OCD-like Psychomotor sx ```
85
Risk factors for late life depression
Female Poor health Disability Poor perceived social support
86
Trial period of antidepressant in elderly should last how long
2-3 months
87
Maintenance period of antidepressants in the elderly
2 years
88
How many elderly do not respond to antidepressants
30%
89
Recovery rate of elderly depression with ECT
80%
90
Which SEs more common in elderly with ECT
Confusion | Cognitive impairment
91
Prognosis of elderly depression
At 2 years 33% are we,, 33% remain depressed
92
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 ```
93
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)
94
How many elderly patients with pseudodementia during depressive episodes go on to develop dementia
40% within 3 years
95
Mania accounts for how much of mood disorders in the elderly?
5-10%
96
One year prevalence of Bipolar in >65?
0.4% compared with 1.4% in younger adults
97
Average age of onset of elderly bipolar
55
98
M:F ratio of elderly bipolar
1:2
99
First line prophylaxis for elderly bipolar
Lithium
100
Prevalence of late onset psychosis in elderly in community
0.1-4%
101
Which gender more affected by late onset psychosis?
Remales
102
Clinical features of late onset psychosis
Paranoid delusions - 90% of patients Auditory hallucinations - 70% Visual hallucinations - 60%
103
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)
104
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 ```
105
Most common psychiatric disorder excluding dementia in elderly
Anxiety
106
Most prevalent anxiety disorder in elderly
Phobia
107
Common anxiety sx in elderly
Hypochondriacal Depressive sx Abuse of sedative drugs and alcohol
108
Most common cause of agoraphobia in the elderly
Physical illness
109
CI of Disulfiram
HTN Cardiac failure CVE IHD
110
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.
111
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
112
Prevalence of PD in the elderly
5-10%
113
Which personality traits may intensify with age?
Depressive illness | Paranoid traits
114
Prevalence of inappropriate sexual behaviour in dementia
7% | 18% in care homes
115
Interventions for sexually inappropriate behaviour in dementia
ABC system
116
When should treatment be initiated in bereavement?
Suicidal ideation Severe functional impairment Signs of severe depression
117
How many of the elderly develop depression needing treatment one year after bereavement of spouse?
10-20%
118
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
119
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
120
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

CASC (16 decks)

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