Old Age Psych Flashcards
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
What is the duration of dementia and what is the diagnosis based on?
6 months duration, usually progressive
Diagnosis based on Hx and collateral
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.
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
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)
What are important areas to ask about in functional impairment?
ADL
Driving
Meds
Finances
Communication
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”
What mental state examinations are available?
MMSE
MOCA-can be useful in showing a deterioration from baseline score
What can a DAT scan be used for?
LBD
Parkinsons
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
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
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
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
What scans could be used to differentiate dementias?
SPECT
PET scan might be more sensitive in younger people
What lobes in particular are affected in alzheimer’s?
Temporal lobes
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
What are the key features of Lewy Body Dementia?
Visual hallucinations
Fluctuations
Parkinsonism
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
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%
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 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
