Old Age Psych Flashcards by Katie Robertson

What is the ABCD of dementia that makes dementia a clinical syndrome?

A for Activities of Daily Living (ADLs)
B for Behavioural and Psychiatric Symptoms of Dementia (BPSD)
C for Cognitive Impairment
D for Decline

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What is the duration of dementia and what is the diagnosis based on?

6 months duration, usually progressive

Diagnosis based on Hx and collateral

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Why is a diagnosis of dementia deferred in delirium?

Because it’s very difficult to know how a person is functioning at their baseline when there’s a superimposed delirium.

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What is looked for and tested in dementia?

PMHx & Medication (particularly anti cholinergics)
Cognitive testing with emphasis on relevant lobes-Neuropsychology
Physical examination & bloods
Supportive evidence from brain imaging

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What are the 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)

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What are important areas to ask about in functional impairment?

ADL
Driving
Meds
Finances
Communication

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Are those with dementia or organic brain syndrome still fit 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”

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What mental state examinations are available?

MMSE

MOCA-can be useful in showing a deterioration from baseline score

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What can a DAT scan be used for?

LBD

Parkinsons

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How is AD diagnosed in primary care (systematic approach)?

A structured and systematic approach is required to ensure the early diagnosis and management of AD. The diagnostic process includes:

Case-finding (symptoms suggestive of cognitive impairment)
Clinical assessment (clinical Hx & collateral Hx, MSE, physical & bloods, cog assessment)
Differentiating AD from other causes of dementia (functional decline & cog impairment-exclude delirium, depression and other causes of ‘dementia’)

Management of AD
- Confirm diagnosis-brain scanning or neuropsychology
- Management & symptomatic treatment
- Follow-up

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What is the aetiology of dementia?

Alzheimer’s dementia – 62%
Vascular dementia – 17%
Mixed Dementia – 10%
Lewy body dementia – 4%

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

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What are some examples of ‘reversible causes of dementia?

Hypercalcaemia – abdominal pain, bone pain, kidney stones, depression and confusion

Normal pressure hydrocephalus=triad of memory difficulties, urinary changes and gait disturbances

Vit B12 deficiency

Hypothyroidism

SDH

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What are the symptoms and signs of AD?

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

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What scans could be used to differentiate dementias?

SPECT

PET scan might be more sensitive in younger people

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What lobes in particular are affected in alzheimer’s?

Temporal lobes

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What are the characteristic signs of vascular dementia?

Unequal distribution of deficits
Evidence of focal impairments on neuro exam
Evidence of cerebrovascular disease - PMHx
STEP WISE DECLINE with sudden changes

Small vessel disease can give gradual decline

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What are the key features of Lewy Body Dementia?

Visual hallucinations
Fluctuations
Parkinsonism

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What present features would support a diagnosis of LBD?

Sensitivity to antipsychotics
Reduced dopamine uptake on SPECT or PET scan
Increased falls
REM sleep disorder

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What questionnaire is used to identify symptoms of Dementia with Lewy bodies?

DIAMOND

What is the sensitivity and specificity of a DAT scan for DLB & what sign is shown on the scan?

Around 85%

The DAT Scan on a normal or AD patient will show normal re-uptake of the dopamine transporter in the head of the caudate nucleus and putamen in the shape of a ‘comma’, whereas in DLB, re-uptake in the putamen is reduced, leading to the ‘full-stop’ sign.

What is the sensitivity and specificity of a DAT scan for DLB & what sign is shown on the scan?

Around 85%

What can be seen on an MRI image of Pick’s disease (frontotemporal dementia)?

Note the difference in the gyro thickness and size of the sulci between the frontotemporal region and the parietal/occipital region

FTD (frontotemporal dementia) what are the signs of it?

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

What behavioural & psychological symptoms are present in dementia?

Agitation (Restlessness, Wandering)
Psychosis (Delusions, Hallucinations)
Affective (Depression, Anxiety, Lability, Hypomania, Apathy)
Disinhibition (Aggression, Sexual)
Behaviour (Eating, toileting, dressing, Sleep-wake cycle)

What drug treatments are available for dementia?

Acetylcholinesterase Inhibitors (AChI) for mild to moderate AD-donepezil, rivastigmine, galantamine Memantine (glutamate receptor antagonist) for moderate to severe AD Antipsychotics (eg. risperidone, quetiapine, amisulpride) Antidepressants (eg. mirtazapine, sertraline) Anxiolytics (eg. lorazepam) Hypnotics (eg. zolpidem, zopiclone, clonazepam) Anticonvulsants (eg. valproate, carbamazepine)

Acetylcholinesterase Inhibitors like Donepezil, Galantamine, Rivastigmine (for AD & LBD) have shown to have what benefits & risks?

Similar clinical effects on MMSE & ADAS COG 10 RCTs showed improved cog function, ADLs & behaviour however small Rx effects Delays time to institutionalisation Risk vs benefit: Nausea, vomiting, diarrhoea Fatigue, insomnia Muscle cramps Headaches, dizziness Syncope Breathing problems

What may in future Mabs be used for in dementia?

Possibly clearing amyloid from brains →slow down disease → longer independence and milder symptoms. Lecanemab 1st treatment for any type of dementia to reverse physical changes and slow decline in memory and thinking.

When are antipsychotics used for dementia?

Not first line except where extreme risk Lowest dose of atypical for shortest time (ideally<12 weeks) - Address treatable causes - Use psychological approaches

What are the non-pharmacological managements of dementia?

- Look for other cause of distress-manage them - ABC approach - Any form of distraction

What are the issues with care homes for people with dementia?

Little Continuity of staff Full of BPSD (Neuropsychiatric disturbance) Psychosocial interventions recommended but medication often has to be relied upon

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

What are 5 points to consider when looking at capacity of a patient?

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?

When asking for an assessment of capacity what are they whys?

What’s the decision for which capacity is required What specifically psychiatric factors call it into question? What efforts have the referring team made to assess it so far?

What are the key points to note when assessing 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

What are the 6 C's of capacity?

Capacity Consent Compliance Coercion Certification Common sense

Can you have different power of attorneys for finance and welfare?

YES

When does guardianship come into play?

When they lack capacity to grant POA 2 med certificates-GP & Psychiatrist Detailed report from MHO (social worker)

What functional illnesses are present in the elderly?

- Depression - Anxiety disorders - Late onset schizophrenia like psychosis

What symptoms of depression are more common in the elderly (different from usual)?

Insomnia Hypochondriasis Suicide Agitation

What is common aetiology of depression?

LOSS - Health - Wealth - Spouse - Work - Home Genetic

What is the management of depression?

Antidepressants- SSRI=1st line (NB Tricyclic side effects-cardiac) Cognitive-behavioural therapy ECT in severe cases need for prophylaxis Most community cases not treated

What is the difference between normal and abnormal grief, mourning and bereavement?

Normal: Alarm Numbness Pining – illusions or hallucinations may occur Depression Recovery and reorganisation Abnormal: PERSISTED beyond 2 months Guilt Thoughts of death Worthlessness Psychomotor retardation Prolonged and marked functional impairment Psychosis

How common is suicide in the 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 loneliness widowed ill health chronic pain recent life events few seeing psychiatrist

What are the clinical features of late onset schizophrenia like psychosis?

Spectrum from circumscribed persecutory delusions to full schizophrenia-like psychosis

What is the aetiology, management and prognosis of late onset schizophrenia like psychosis?

Aetiology=Sensory Loss, Social isolation, Genetic ?minor abnormalities Management= Often needs compulsory admission, NEUROLEPTICS, Increase social contact Prognosis=May fail to regain insight, High relapse if stop neuroleptics