old age (dementia) Flashcards
ABCD of dementia?
A for Activities of Daily Living (ADLs)
B for Behavioural and Psychiatric Symptoms of Dementia (BPSD)
C for Cognitive Impairment
D for Decline
cognitive features of dementia?
-Memory (dysmnesia)
Plus one or more of
-dysphasia (communication)
expressive
receptive
- dyspraxia (inability to carry out motor skills)
- dysgnosia (not recognising objects)
- dysexecutive functioning (initiation, inhibition, set-shifting, abstraction)
what question is important to ask in patients with dementia?
Functional impairment
Cars - Fitness to Drive
notify DVLA at diagnosis
if early dementia license may be yearly
“those with poor short term memory, disorientation or lack of insight should almost certainly not drive”
types of dementia
Alzheimer’s dementia – 62%
Vascular dementia – 17%
Mixed Dementia – 10%
Lewy body dementia – 4%
what is the aetiology of dementia?
Frontotemporal (Picks) (behavioural, PNFA: progressive non fluent aphasia, semantic)
Alcohol; ARBD (alcohol dementia/ Korsakoffs (thiamine deficiency))
Subcortical - Parkinson’s, Huntington’s, HIV
Prion Protein eg CJD
what are some reversible causes of dementia?
Delirium Normal pressure hydrocephalus Subdural haemorrhage Tumours Vitamin B12 deficiency Hypothyroidism Hypercalcaemia Alcohol misuse Neurosyphilis Drugs
Hypercalcaemia – abdominal pain, bone pain, kidney stones, depression and confusion
main features of Alzheimer’s disease?
Early impairment of memory and executive function
Gradual progression with often unclear onset
Main features:
Amyloid plaques & tau tangles
Atrophy following neuron death
Reduction in Acetylcholine
vascular dementia progression?
Step wise decline with sudden changes (every time a vessel gets affected
Small vessel disease can give gradual decline
what will you see on examination of someone with dementia?
Unequal distribution of deficits
Evidence of focal impairments on neuro exam
Evidence of cerebrovascular disease - PMHx
diagnosis if heavy calcified in left frontal region in a MRI of brain
meningioma
dementia Lewy body key features (DLB)
Visual hallucinations
Fluctuations
Parkinsonism
dementia Lewy body supportive changes (DLB)
Sensitivity to antipsychotics
Reduced dopamine uptake on SPECT or PET scan
Increased falls
REM sleep disorder
what do you see on a DATscan in DLB
re-uptake in the putamen is reduced, leading to the ‘full-stop’ sign.
Pick’s disease Axial MRI description
cerebral atrophy -frontal and temporal regions
gyro thickness and size of the sulci between the frontotemporal region and the parietal/occipital region
Frontotemporal Dementia (FTD) symptoms
Behavioural disorder – personality change
Can be early onset
Early emotional blunting
Speech disorder - altered output, stereotypy, echolalia, perseveration, mutism
Neuropsychology - frontal dysexecutive syndrome. Memory, praxis and visuospatial function not severely impaired
Neuroimaging - abnormalities in frontotemporal lobes
Neurological signs commonly absent early; parkinsonism later; MND in a few; autonomic; incontinence; primitive reflexes
drug treatment of dementia
Acetylcholinesterase Inhibitors (AChI):
donepezil
rivastigmine
galantamine
Memantine
Antidepressants
anxiolytics
anticonvulsants
Examples of Acetylcholinesterase Inhibitors
and
side affects
Donepezil, Galantamine, Rivastigmine
Nausea, vomiting, diarrhoea Fatigue, insomnia Muscle cramps Headaches, dizziness Syncope Breathing problems
what is capacity?
Capacity is the ability to understand information relevant to a decision or action, and to appreciate the reasonably foreseeable consequences of not taking action or decision
5 points of capacity
1) Does the patient UNDERSTAND the information?
2) Does the patient RETAIN the information long enough to make a decision?
3) Can the patient COMMUNICATE the decision?
4) Can the patient WEIGH UP the information in order to make a decision?
5) Does the patient BELIEVE the information they are given?
8 key points of capacity
1) A patient is deemed to have capacity unless proven otherwise
2) A patient should be supported to make a decision
3) A person can not be deemed to incapable if their decision is eccentric or unwise
4) Anything done for the patient must be in their best interest
5) Always use the least restrictive option
6) Capacity should be assessed on the topic of question
7) Patient’s should be assessed at their ‘peak time’
8) Speak to family to get historic views? Advanced statement
6 Cs of capacity
Capacity Consent Compliance Coercion Certification Common sense
suicide in elderly
Same rate as for under 25 age group
Half the rate of other age groups
Males more than females
Most are depressed
DSH is rare in the elderly
causes of suicide in the elderly?
loneliness widowed ill health chronic pain recent life events few seeing psychiatrist
