Old Age & Liason Psych Flashcards
why would you visit an old age patient at home rather than in clinic?
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
list common cognitive assessments
MOCA
ACE R
MMSE
AMTS
limitations of cognitive tests
they can under estimate impairment - especially in the more simple one
culture bound - english 2nd language can be a barrier
affected by sensory impairment
what is the first function to go in dementia & how would this present
executive function - lack of ability to problem solve
name a somatic early sign of dementia
anosmia
what is seen on MRI of dementia
cortical thinning - more likely in posterior than frontal lobe
generalised atrophy - large ventricles
what is pathognomonic of AD on MRI
atrophied asymmetrical hippocampi
is an atrophied cortex on MRI diagnostic of dementia?
NO - never diagnose/rule out dementia based on a scan
describe time course of dementia
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
icd 11 definition of dementia
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
list cognitive Sx of dementia
memory
executive functioning
**
list non cognitive Sx of dementia
apathy
depression
irritability
agitation
delusions / hallucinations
disinhibition
wandering
epidemiology of dementia
7% of over 65s
20% of over 80s
how many people under 65 have dementia in UK
40,000
what proportion of dementia cases are never diagnosed
1/3
what is the time between onset and diagnosis of dementia
2 years
% of each of the dementias
75% AD
15% vascular
10% LBD
2% FTD
which dementia is over-diagnosed & why
vascular
- scan shows vascular change so Drs think vascular but this is present in most dementia cases
what % of antemortem diagnoses are correct for dementia
70-80%
how does vascular dementia present
sudden onset dementia Sx due to stroke(s)
stepwise deterioration
fluctuating course
AF !! and DM/HTN/obese
presentation of AD
INSIDIOUS ONSET
progressive cognitive decline over years
gradual loss of function
LBD presentation
parkinsonism
fluctuating cognitive impairment
vivid visual hallucinations
REM sleep behaviour disorder - act out a dream
falls
what are LBD patients sensitive too
antipsychotics
presentation of FTD
lose executive function
lose empathic control / filters –> disinhibition
how do you diagnose dementia
exclude mimic conditions - depression / thyroid / delirium
define characteristics
principle of dementia diagnosis
assess risk - driving / self neglect / exploitation
assess capacity - will / LPA
counselling & education - family and patient
regular review
what is the key legal feature you must consult patient about with dementia
must inform DVLA - may have to stop driving depending on features of dementia
Ix for dementia q
Hx from patient
Hx from NOK
cognitive examination
physical assessment
investigations - TFTs
MRI
DDx of dementia
mild cognitive disorder
depression
delirium
dysphasia
learning difficulties
psychotic disorders - burnout phase of disorder
iatrogenic
what is depressive pseudodementia
symptoms of dementia - mainly attentional so affects memory
don’t say they are low mood, but have anhedonia, anergia, poor sleep etc
progress of people with delirium
can progress into dementia or never fully recovery so becomes dementia
why diagnose dementia?
explanation for memory / personality changes
initiate Tx
plan for future - advanced decisions, wills
risk assess - finances, driving
do people anticipate a diagnosis of dementia
initially they lack insight so don’t think they are unwell
once testing done, 95% suspect they have dementia
drugs for dementia
ACHIs
NMDA antagonist
name a NMDA antagonist
memantine
name 3 ACHIs
donepezil
rivastigmine
galantamine
are there are any disease modifying drugs for dementia
NO - some monoclonal ABs trials but not effective
what effect do NMDA antagonist / ACHIs have in dementia
symptomatic drugs
which dementia drug has the most adverse effects
rivastigmine
non drug Tx for dementia
cognitive stimulation - puzzles, crosswords etc
what drugs should be avoided in dementia
anti psychotics
symptoms that can masquerade as dementia
undetected pain or discomfort
side effects of medication
normal behaviour for their culture / history
constipation
infection - UTI / COVID
environmental features eg temp
can a life event trigger dementia
NO - it is a natural process that is independent of life events
what is delirium also known as
acute confusional state
define delirium
disturbance in attention (direct/focus/sustain/shift) and a disturbance in awareness (disorientated)
+/- cognitive impairment inc language
how does delirium develop
quickly over hours or days
fluctuating attention / awareness over the day
when can delirium not happen
if there is an established/ evolving neurocognitive disorder or a reduced arousal level eg coma
what causes delirium
physiological consequence of another medical condition / substance intoxication or withdrawal
epidemiology of delirium
10-20% medical/surgical inpatients
1% in community
who is most at risk of delirium
elderly
pre-existing dementia
sensory impairment
very young
post op
burn victims
alcohol/benzo dependent
serious illness
DDx of delirium
mood disorder
psychotic illness
post ictal state
dementia
when is a psychotic illness less likely
in elderly patient / medically hospitalised patient
primary goals of treating delirium
establish underlying cause & Tx
provide environmental / supportive measures
avoid sedation unless severely agitated
regular clinic review / follow up
what environmental / supportive measures can be done for delirium
educate staff / family
reality orientation - use clocks / calendars
make environment safe - adequate lighting, reduced unnecessary noise, mobilise where possible
what medication would be used for sedation in delirium
small dose haloperidol
what drug would be avoided in delirium agitation
benzos - can worsen the agitation
what is delirium tremens
acute confusional state secondary to alcohol withdrawal
MEDICAL EMERGENCY
when does DT happen
1-7 days after last drink, peaks after 2 days
who gets DT
Hx of dependene
previous withdrawal
drank >10 units of alcohol daily for previous 10 days
currently experiencing withdrawal
Sx of DT
coarse tremor
sweating
insomnia
tachycardia
N&V
psychomotor agitation
visual / auditory / tactile hallucinations - Lilliputian
course of DT
mared fluctuations in severity hour by hour, usually worse at night
severe DT Sx
heavy sweating
fear / paranoia
progressive temp
subtypes of delirium
hyperactive = agitated, not sleeping, manic-like
mixed = bit of both
hypoactive = drowsy, depression-like
which is the most common type of delirium
mixed
contrast delirium vs dementia
delirium = acute, fluctuating course, impaired awareness, disturbed attention
dementia = insidious, gradual deterioration, good awareness/attention until advanced
contrast memory of dementia and delirium
dementia = poor short term
delirium = poor working and immediate recall
contrast delusions of dementia and delirium
delirium = short lived / changing
dementia = fixed
contrast sleep of dementia and delirium
delirium = fragmented
dementia = sleep wake reversal
Ix for old age psych
hx, exam, collateral (inc GP)
screen for organic causes - bloods, urine dip, CXR, CTH
ACE3
ask about social - falls / ADL / lonliness
bloods for old age psych
FBC - anaemia
U&Es - esp Na
LFTs
TFTs
HbA1c
B12
folate
Ca
Syphilis
HIV
Mx of old age psych
Bio
- treat physical causes
- correct hearing and eye sight
Psycho
- CBT
- Supportive psychotherapy
- HTT referral
Social
- safeguarding
- respite
- risk Mx
what is the most common psych condition in old age
depression
casues of depression in old age
care homes
social isolation
physical illness
bereavement
feeling a burden
suicide risk factors in old age
male
widowed
older
social isolation
physical illness
pain
alcohol
depression
how can depression present in old age
pseudodementia
Tx of depression in old age
SSRIs or mirtazapine
how does Tx of depression in old age differ from normal
increased risk of adverse effects
give longer trials in old age
may need higher dose
less likely to use CBT
why is mirtazapine beneficial in old age
increases appetite and betters sleep, which is useful in old age
what % of dementia pts have depression
15
how does Tx of depression in dementia differ
antidepressants less effective
when is ECT used
severe or life threatening depression
Tx resistant
catatonia
risks of ECT
anaesthetics risks
short term anterograde memory loss
what is psychotic depression
severe depression + psychosis
- mood congruent delusions: guilt, poverty, nihilistic
Tx of psychotic depression
antidepressant + antipsychotic
ECT if severe
72 year old man with excessive shopping, impulsivity, eccentric clothes, forgetting things. made an allegation that hes being financially abused. Dx?
Bipolar affective disorder
Tx of BPAD
stop antidepressant
antipsychotics
mood stabiliser for life - Li
side effects of Li in older person
renal / thyroid dysfunction
what is late onset schizo
over 45
how common is late onset schizo
very uncommon
prevalencfe of psychotic disorders in old age
delusional disorder > schizophrenia > acute / transient psychotic disorder
late onset schizo vs normal schizo
fewer negative Sx
less social withdrawal
less cognitive / personality effects
higher rates of hospital admission
what must you do in late onset schizo
organic cause
risk factors for late onset schizo
female
sensory impairment
social isolation
poor social functioning
Tx of late onset schizo
antipsychotics - must smaller dose
risks of Tx in late onset schizo
extra-pyramidal Sx
falls
cardiac
sedation
hyperprolactinaemia
osteoporosis
death
types of antipsychotics used in old age
amisulpride
olanzapine
risperidone
maybe aripiprazole
what to remember in Tx in old age schizo (2)
drugs have longer half life and higher plasma levels, so give smaller doses
only treat if risk / distress
what is BPSD
behavioural and psychological symptoms in dementia
Sx of BPSD
agitation, mood disorder, psychosis
Tx of BPSD
check for pain / delirium first
non pharmacological methods first
antipsychotics - risperidone
analgesia, antidepressants, memantine
risks of antipsychotics Tx of BPSD
hip fracture
pneumonia
stroke !!
cognitive decline
death - 20-30%, worse with atypicals
how does substance misuse present in old age
30% alcohol dependence
reduced life expectancy
prescription medication dependency
why is there a reduced life expectancy in substance misuse in old age
falling over
head trauma
reduced self care
korsakoff’s syndrome mortality
10-15% death rate
what is Korsakoff’s
chronic thiamine deficiency
Sx of Korsakoff’s
irreversible anterograde amnesia
confabulation
Sx of Wernickes
confusion
ataxia
opthalmoplegia
what is liason psych
link between physical and mental health
how do psych issues cause physical issues
chronic pain can lead to suicide
poor pain control
increased use of acute services
reduced engagement in therapies etc
less likely to take meds
how do physical issues cause psych issues
chronic issues –> depression
life changing injuries / sports –> grief
delirium
pregnancy –> psychosis
how can psych meds cause pshyical issues
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
serotonin syndrome Sx
agitation, confusion, restlessness
autonomic dysfunction - HTN, tachycardia
increased tremor, rigidity
–> seizures / death
how can physical health meds affect mental health
roaccutane –> depression
steroids –> psychosis
bisoprolol –> vivid dreams, insomnia
ketamine –> psychosis
interferon antivirals –> depression
role of psych liason
advise patients and Drs
signposting pts to communitu services
liase with CMHTs, social services, GPs, relatives
diagnose, risk assess & Tx
when is rapid tranq used
last option if all other drugs failed / verbal deescalation failed
types of rapid tranq drugs
lorazepam !!!
promethazine
haloperidol
how is rapid tranq given
PO preferable, otherwise IM
managing risk eg falls / breathing
when are lower doses of rapid tranq given
delirium / underlying physical illness
what must be done post rapid tranq
monitor physical state post administration
what happens if rapid tranq fails
call security / police to help
expedite MHA assessment & transfer to psych ward
what is section 136
inc who / time / what
police powers
detains place of safety
24hrs
what is section 5(2)
inc who / time / what
Drs (not F1) holding power
72hrs
what is section 5(4)
inc who / time / what
nurses holding power
6 hours
what is section 2/3
inc who / time / what
for doctors
detention for assessment / treatment
28 days / 6 months
when was MHA made
1983
can you treat someone under 5(2)
NO - only a holding power not for treatment
can you use a 5(4) and then a 5(2) ? how long will they be hled for?
Yes but max holding is still 72 hours not 78 hours
can section 3s be renewed continuously
YES
where can you use a section 5(2) and 5(4)?
only if someone has been ADMITTED
- not in A&E as not admitted, but AMU is fine
can any Dr use a 5(2) or is it only psychiatrists?
ANY Dr (not F1)
when was MCA made
2005
what is the MCA for
assessing CAPACITY for any disorder / decision, not just mental health
4 elements of capcity
understand
retain
weigh up
communicate
5 principles of capacity
presumption of capacity in adults
support to make decision - eg translator / glasses
ability to make unwise decisions
best interests
least restrictive
what is DOLS
deprivation of liberty safeguards
when is MCA used
disorder of mind / brain - non psychiatric treatment and Mx
when is DOLS used
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
can physical health issues be treated under MHA
only if they are a direct result of their mental health condition
a sectioned schizophrenic patient refuses to take their diabetes medication, when/how can you force them to take it?
ONLY if they lack capacity, so you treat them under MCA
can not treat DM under the MHA
