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Y5 Psych > Old Age & Liason Psych > Flashcards

Old Age & Liason Psych Flashcards

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1
Q

why would you visit an old age patient at home rather than in clinic?

A

less anxious for them, so they will be more like their normal self
you can see their natural environment and see how they are coping at home

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2
Q

list common cognitive assessments

A

MOCA
ACE R
MMSE
AMTS

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3
Q

limitations of cognitive tests

A

they can under estimate impairment - especially in the more simple one
culture bound - english 2nd language can be a barrier
affected by sensory impairment

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4
Q

what is the first function to go in dementia & how would this present

A

executive function - lack of ability to problem solve

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5
Q

name a somatic early sign of dementia

A

anosmia

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6
Q

what is seen on MRI of dementia

A

cortical thinning - more likely in posterior than frontal lobe
generalised atrophy - large ventricles

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7
Q

what is pathognomonic of AD on MRI

A

atrophied asymmetrical hippocampi

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8
Q

is an atrophied cortex on MRI diagnostic of dementia?

A

NO - never diagnose/rule out dementia based on a scan

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9
Q

describe time course of dementia

A

initially - some minor executive function issues
after 2 years - forgetting key dates, finances, poor self care
after 4 years - significant memory problems, wandering around at night
after 7 years - can’t talk, toilet or interact
after 8 years - death

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10
Q

icd 11 definition of dementia

A

marked impairment in 2 or more cognitive domains relative to that expected given the individual’s age and general premorbid level of cognitive functioning, which represents a decline from the individual’s previous level of functioning
- not attributable to normal aging
- severe enough to significantly interfere with independence in an individual’s performance of activities of daily living

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11
Q

list cognitive Sx of dementia

A

memory
executive functioning
**

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12
Q

list non cognitive Sx of dementia

A

apathy
depression
irritability
agitation
delusions / hallucinations
disinhibition
wandering

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13
Q

epidemiology of dementia

A

7% of over 65s
20% of over 80s

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14
Q

how many people under 65 have dementia in UK

A

40,000

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15
Q

what proportion of dementia cases are never diagnosed

A

1/3

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16
Q

what is the time between onset and diagnosis of dementia

A

2 years

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17
Q

% of each of the dementias

A

75% AD
15% vascular
10% LBD
2% FTD

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18
Q

which dementia is over-diagnosed & why

A

vascular
- scan shows vascular change so Drs think vascular but this is present in most dementia cases

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19
Q

what % of antemortem diagnoses are correct for dementia

A

70-80%

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20
Q

how does vascular dementia present

A

sudden onset dementia Sx due to stroke(s)
stepwise deterioration
fluctuating course
AF !! and DM/HTN/obese

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21
Q

presentation of AD

A

INSIDIOUS ONSET
progressive cognitive decline over years
gradual loss of function

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22
Q

LBD presentation

A

parkinsonism
fluctuating cognitive impairment
vivid visual hallucinations
REM sleep behaviour disorder - act out a dream
falls

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23
Q

what are LBD patients sensitive too

A

antipsychotics

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24
Q

presentation of FTD

A

lose executive function
lose empathic control / filters –> disinhibition

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25
Q

how do you diagnose dementia

A

exclude mimic conditions - depression / thyroid / delirium
define characteristics

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26
Q

principle of dementia diagnosis

A

assess risk - driving / self neglect / exploitation
assess capacity - will / LPA
counselling & education - family and patient
regular review

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27
Q

what is the key legal feature you must consult patient about with dementia

A

must inform DVLA - may have to stop driving depending on features of dementia

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28
Q

Ix for dementia q

A

Hx from patient
Hx from NOK
cognitive examination
physical assessment
investigations - TFTs
MRI

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29
Q

DDx of dementia

A

mild cognitive disorder
depression
delirium
dysphasia
learning difficulties
psychotic disorders - burnout phase of disorder
iatrogenic

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30
Q

what is depressive pseudodementia

A

symptoms of dementia - mainly attentional so affects memory
don’t say they are low mood, but have anhedonia, anergia, poor sleep etc

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31
Q

progress of people with delirium

A

can progress into dementia or never fully recovery so becomes dementia

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32
Q

why diagnose dementia?

A

explanation for memory / personality changes
initiate Tx
plan for future - advanced decisions, wills
risk assess - finances, driving

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33
Q

do people anticipate a diagnosis of dementia

A

initially they lack insight so don’t think they are unwell
once testing done, 95% suspect they have dementia

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34
Q

drugs for dementia

A

ACHIs
NMDA antagonist

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35
Q

name a NMDA antagonist

A

memantine

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36
Q

name 3 ACHIs

A

donepezil
rivastigmine
galantamine

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37
Q

are there are any disease modifying drugs for dementia

A

NO - some monoclonal ABs trials but not effective

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38
Q

what effect do NMDA antagonist / ACHIs have in dementia

A

symptomatic drugs

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39
Q

which dementia drug has the most adverse effects

A

rivastigmine

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40
Q

non drug Tx for dementia

A

cognitive stimulation - puzzles, crosswords etc

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41
Q

what drugs should be avoided in dementia

A

anti psychotics

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42
Q

symptoms that can masquerade as dementia

A

undetected pain or discomfort
side effects of medication
normal behaviour for their culture / history
constipation
infection - UTI / COVID
environmental features eg temp

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43
Q

can a life event trigger dementia

A

NO - it is a natural process that is independent of life events

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44
Q

what is delirium also known as

A

acute confusional state

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45
Q

define delirium

A

disturbance in attention (direct/focus/sustain/shift) and a disturbance in awareness (disorientated)
+/- cognitive impairment inc language

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46
Q

how does delirium develop

A

quickly over hours or days
fluctuating attention / awareness over the day

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47
Q

when can delirium not happen

A

if there is an established/ evolving neurocognitive disorder or a reduced arousal level eg coma

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48
Q

what causes delirium

A

physiological consequence of another medical condition / substance intoxication or withdrawal

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49
Q

epidemiology of delirium

A

10-20% medical/surgical inpatients
1% in community

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50
Q

who is most at risk of delirium

A

elderly
pre-existing dementia
sensory impairment
very young
post op
burn victims
alcohol/benzo dependent
serious illness

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51
Q

DDx of delirium

A

mood disorder
psychotic illness
post ictal state
dementia

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52
Q

when is a psychotic illness less likely

A

in elderly patient / medically hospitalised patient

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53
Q

primary goals of treating delirium

A

establish underlying cause & Tx
provide environmental / supportive measures
avoid sedation unless severely agitated
regular clinic review / follow up

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54
Q

what environmental / supportive measures can be done for delirium

A

educate staff / family
reality orientation - use clocks / calendars
make environment safe - adequate lighting, reduced unnecessary noise, mobilise where possible

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55
Q

what medication would be used for sedation in delirium

A

small dose haloperidol

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56
Q

what drug would be avoided in delirium agitation

A

benzos - can worsen the agitation

57
Q

what is delirium tremens

A

acute confusional state secondary to alcohol withdrawal
MEDICAL EMERGENCY

58
Q

when does DT happen

A

1-7 days after last drink, peaks after 2 days

59
Q

who gets DT

A

Hx of dependene
previous withdrawal
drank >10 units of alcohol daily for previous 10 days
currently experiencing withdrawal

60
Q

Sx of DT

A

coarse tremor
sweating
insomnia
tachycardia
N&V
psychomotor agitation
visual / auditory / tactile hallucinations - Lilliputian

61
Q

course of DT

A

mared fluctuations in severity hour by hour, usually worse at night

62
Q

severe DT Sx

A

heavy sweating
fear / paranoia
progressive temp

63
Q

subtypes of delirium

A

hyperactive = agitated, not sleeping, manic-like
mixed = bit of both
hypoactive = drowsy, depression-like

64
Q

which is the most common type of delirium

A

mixed

65
Q

contrast delirium vs dementia

A

delirium = acute, fluctuating course, impaired awareness, disturbed attention
dementia = insidious, gradual deterioration, good awareness/attention until advanced

66
Q

contrast memory of dementia and delirium

A

dementia = poor short term
delirium = poor working and immediate recall

67
Q

contrast delusions of dementia and delirium

A

delirium = short lived / changing
dementia = fixed

68
Q

contrast sleep of dementia and delirium

A

delirium = fragmented
dementia = sleep wake reversal

69
Q

Ix for old age psych

A

hx, exam, collateral (inc GP)
screen for organic causes - bloods, urine dip, CXR, CTH
ACE3
ask about social - falls / ADL / lonliness

70
Q

bloods for old age psych

A

FBC - anaemia
U&Es - esp Na
LFTs
TFTs
HbA1c
B12
folate
Ca
Syphilis
HIV

71
Q

Mx of old age psych

A

Bio
- treat physical causes
- correct hearing and eye sight
Psycho
- CBT
- Supportive psychotherapy
- HTT referral
Social
- safeguarding
- respite
- risk Mx

72
Q

what is the most common psych condition in old age

A

depression

73
Q

casues of depression in old age

A

care homes
social isolation
physical illness
bereavement
feeling a burden

74
Q

suicide risk factors in old age

A

male
widowed
older
social isolation
physical illness
pain
alcohol
depression

75
Q

how can depression present in old age

A

pseudodementia

76
Q

Tx of depression in old age

A

SSRIs or mirtazapine

77
Q

how does Tx of depression in old age differ from normal

A

increased risk of adverse effects
give longer trials in old age
may need higher dose
less likely to use CBT

78
Q

why is mirtazapine beneficial in old age

A

increases appetite and betters sleep, which is useful in old age

79
Q

what % of dementia pts have depression

A

15

80
Q

how does Tx of depression in dementia differ

A

antidepressants less effective

81
Q

when is ECT used

A

severe or life threatening depression
Tx resistant
catatonia

82
Q

risks of ECT

A

anaesthetics risks
short term anterograde memory loss

83
Q

what is psychotic depression

A

severe depression + psychosis
- mood congruent delusions: guilt, poverty, nihilistic

84
Q

Tx of psychotic depression

A

antidepressant + antipsychotic
ECT if severe

85
Q

72 year old man with excessive shopping, impulsivity, eccentric clothes, forgetting things. made an allegation that hes being financially abused. Dx?

A

Bipolar affective disorder

86
Q

Tx of BPAD

A

stop antidepressant
antipsychotics
mood stabiliser for life - Li

87
Q

side effects of Li in older person

A

renal / thyroid dysfunction

88
Q

what is late onset schizo

A

over 45

89
Q

how common is late onset schizo

A

very uncommon

90
Q

prevalencfe of psychotic disorders in old age

A

delusional disorder > schizophrenia > acute / transient psychotic disorder

91
Q

late onset schizo vs normal schizo

A

fewer negative Sx
less social withdrawal
less cognitive / personality effects
higher rates of hospital admission

92
Q

what must you do in late onset schizo

A

organic cause

93
Q

risk factors for late onset schizo

A

female
sensory impairment
social isolation
poor social functioning

94
Q

Tx of late onset schizo

A

antipsychotics - must smaller dose

95
Q

risks of Tx in late onset schizo

A

extra-pyramidal Sx
falls
cardiac
sedation
hyperprolactinaemia
osteoporosis
death

96
Q

types of antipsychotics used in old age

A

amisulpride
olanzapine
risperidone
maybe aripiprazole

97
Q

what to remember in Tx in old age schizo (2)

A

drugs have longer half life and higher plasma levels, so give smaller doses
only treat if risk / distress

98
Q

what is BPSD

A

behavioural and psychological symptoms in dementia

99
Q

Sx of BPSD

A

agitation, mood disorder, psychosis

100
Q

Tx of BPSD

A

check for pain / delirium first
non pharmacological methods first
antipsychotics - risperidone
analgesia, antidepressants, memantine

101
Q

risks of antipsychotics Tx of BPSD

A

hip fracture
pneumonia
stroke !!
cognitive decline
death - 20-30%, worse with atypicals

102
Q

how does substance misuse present in old age

A

30% alcohol dependence
reduced life expectancy
prescription medication dependency

103
Q

why is there a reduced life expectancy in substance misuse in old age

A

falling over
head trauma
reduced self care

104
Q

korsakoff’s syndrome mortality

A

10-15% death rate

105
Q

what is Korsakoff’s

A

chronic thiamine deficiency

106
Q

Sx of Korsakoff’s

A

irreversible anterograde amnesia
confabulation

107
Q

Sx of Wernickes

A

confusion
ataxia
opthalmoplegia

108
Q

what is liason psych

A

link between physical and mental health

109
Q

how do psych issues cause physical issues

A

chronic pain can lead to suicide
poor pain control
increased use of acute services
reduced engagement in therapies etc
less likely to take meds

110
Q

how do physical issues cause psych issues

A

chronic issues –> depression
life changing injuries / sports –> grief
delirium
pregnancy –> psychosis

111
Q

how can psych meds cause pshyical issues

A

Li –> acne / thyroid issues / hair loss
clozapine –> agranulocytosis
olanzapine –> metabolic issues eg dyslipidaemia, DM
diazepam –> withdrawal
serotonin syndrome
antipsychotics / antidepressants –> long QT syndrome - torsade de pointes

112
Q

serotonin syndrome Sx

A

agitation, confusion, restlessness
autonomic dysfunction - HTN, tachycardia
increased tremor, rigidity
–> seizures / death

113
Q

how can physical health meds affect mental health

A

roaccutane –> depression
steroids –> psychosis
bisoprolol –> vivid dreams, insomnia
ketamine –> psychosis
interferon antivirals –> depression

114
Q

role of psych liason

A

advise patients and Drs
signposting pts to communitu services
liase with CMHTs, social services, GPs, relatives
diagnose, risk assess & Tx

115
Q

when is rapid tranq used

A

last option if all other drugs failed / verbal deescalation failed

116
Q

types of rapid tranq drugs

A

lorazepam !!!
promethazine
haloperidol

117
Q

how is rapid tranq given

A

PO preferable, otherwise IM
managing risk eg falls / breathing

118
Q

when are lower doses of rapid tranq given

A

delirium / underlying physical illness

119
Q

what must be done post rapid tranq

A

monitor physical state post administration

120
Q

what happens if rapid tranq fails

A

call security / police to help
expedite MHA assessment & transfer to psych ward

121
Q

what is section 136
inc who / time / what

A

police powers
detains place of safety
24hrs

122
Q

what is section 5(2)
inc who / time / what

A

Drs (not F1) holding power
72hrs

123
Q

what is section 5(4)
inc who / time / what

A

nurses holding power
6 hours

124
Q

what is section 2/3
inc who / time / what

A

for doctors
detention for assessment / treatment
28 days / 6 months

125
Q

when was MHA made

A

1983

126
Q

can you treat someone under 5(2)

A

NO - only a holding power not for treatment

127
Q

can you use a 5(4) and then a 5(2) ? how long will they be hled for?

A

Yes but max holding is still 72 hours not 78 hours

128
Q

can section 3s be renewed continuously

A

YES

129
Q

where can you use a section 5(2) and 5(4)?

A

only if someone has been ADMITTED
- not in A&E as not admitted, but AMU is fine

130
Q

can any Dr use a 5(2) or is it only psychiatrists?

A

ANY Dr (not F1)

131
Q

when was MCA made

A

2005

132
Q

what is the MCA for

A

assessing CAPACITY for any disorder / decision, not just mental health

133
Q

4 elements of capcity

A

understand
retain
weigh up
communicate

134
Q

5 principles of capacity

A

presumption of capacity in adults
support to make decision - eg translator / glasses
ability to make unwise decisions
best interests
least restrictive

135
Q

what is DOLS

A

deprivation of liberty safeguards

136
Q

when is MCA used

A

disorder of mind / brain - non psychiatric treatment and Mx

137
Q

when is DOLS used

A

patients who lack capacity but agree to Tx - to ensure the patients are being treated in their best interest
prevent dementia pts etc from leaving the ward / bed if it is not in their best interests

138
Q

can physical health issues be treated under MHA

A

only if they are a direct result of their mental health condition

139
Q

a sectioned schizophrenic patient refuses to take their diabetes medication, when/how can you force them to take it?

A

ONLY if they lack capacity, so you treat them under MCA
can not treat DM under the MHA

Y5 Psych (10 decks)

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