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Psychiatry > Old Age Psych > Flashcards

Old Age Psych Flashcards

1
Q

In which age groups are dementias most prevalent?

A

80-99

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2
Q

In a 500 bed general hospital how many beds are likely to be taken up by old peeps?

A

66%

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3
Q

Of the 66% of oldies how many (roughly) are likely to have delirium, dementia and depression?

A

About 1/3 for each pathology

Stats below are for average general hospital - 500 people

  • 330 beds will be occupied by older people.
  • 220 will have a mental disorder
  • 96 will have depression
  • 66 will have delirium
  • 102 will have dementia
  • 23 will have other major mental health problems.
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4
Q

What is the ABCD of dementia (clinical syndrome)?

A
  • A for Acitivities of Daily Living (ADLs)
  • B for Behavioural and Psychiatric Symptoms of Dementia (BPSD)
  • C for Cognitive Impairment
  • D for Decline
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5
Q

What are cognitive features of dementia?

A
  • Memory (dysmnesia)
    • Plus one or more of
    • dysphasia (communication)
      • expressive
      • receptive
    • dyspraxia (inability to carry out motor skills)
    • dysgnosia (not recognising objects)
    • dysexecutive functioning
  • Functional decline
  • ADLs
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6
Q

What do MMSE scores correlate to?

A

correlate with ability to perform daily activities

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7
Q

What are common neuropsychiatric disturbances?

A
  • Psychosis
  • Depression
  • Altered circadian rhythm
  • Agitation
  • Anxiety
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8
Q

What is the approach to diagnosing alzheimers disease in primary care?

A
  1. Case finding: symptoms suggestings cognitive impairment
  2. Clinical assessment: history and collateral history, Mental state examination, Physical and bloods, Cognitive assessment
  3. DDx: exlude delirium, depression
  4. Specialist Referral: *confirm diagnosis, brain scanning, neuropsychology, *patient and caregiver counselling, *Mx and symptomatic treatment, * follow up
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9
Q

Please explain the differences between delirium and dementia:

A
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10
Q

Please explain the differences between dementia and depression:

A
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11
Q

In what ways can we assess, or rather, what tools can we use to assess someones cognition?

A

MMSE

MOCA (hmmm tasty, 10/10 Kilau)

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12
Q

Case study 1

  • 78 year old woman referred by GP with 3 year history of gradual and progressive deterioration in ‘memory’
  • On cognitive testing she has some dysmnesia and dysexecutive dysfunction
  • Clear functional impairment – reliant on daughter
  • No focal neurological signs
  • No history of vascular disease or risk factors
  • Diagnosis? Would you order imaging?
A
  • Alzheimer’s disease
  • Order MRI and look at coronal planes - best view to assess atrophy in the the medial temporal lobes
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13
Q

Case study 2

  • 74 year old woman referred by GP with subtle personality changes, lack of motivation and progressive apathy.
  • On cognitive testing she has some executive dysfunction but intact memory
  • Reports constant dull headache
  • No focal neurological signs
  • Diagnosis? Imaging?
A
  • Obvious heavily calcified lesion in left frontal region suggestive of meningioma
  • Referred to neurosurgeons who resected meningioma
  • After period of recovery cognition and personality revovered
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14
Q

How does normal compare with alzheimers with frontotemporal dementia on SPECT?

A
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15
Q

What are the features and SSx of dementia with Lewy Bodies?

A
  • Dementia. Amnesia not prominent.
    • Deficits of attention, frontal executive, visuospatial
  • Dx less likely if stroke disease or other brain/systemic illness.
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16
Q

What is the criteria for dementia with lewy bodies?

A
  • Two = probable, One = possible
  • a. Fluctuation - marked, important feature
  • b. Visual hallucinations
  • c. Parkinsonism
    1. Suggestive - REM sleep disorder, severe antipsych sensitivity, abnormal DAT scan
17
Q

Which investigation would you order for Dementia with Lewy bodies and what would be seen?

A

DATScan

(Sensitivity and specificity of around 85%.)

The DATScan 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

18
Q

What are features/SSx of frontotemporal dementia?

A
  • Behavioural disorder – personality change
  • Can be early onset
  • Early emotional blunting
  • Speech disorder - altered output, stereotypy, echolalia, perseveration, mutism
  • Neurological signs commonly absent early; parkinsonism later; MND in a few; autonomic; incontinence; primitive reflexes
19
Q

What are the neuropsychological effects of frontotemporal dementia?

A
  • Neuropsychology - frontal dysexecutive syndrome. Memory, praxis and visuospatial function not severely impaired
20
Q

What would be seen on imaging for frontotemporal dementia?

A

Neuroimaging - abnormalities in frontotemporal lobes

21
Q

Case study 4

  • 69 year old man brought in by daughter concerned about his memory
  • Symptoms started a year prior, when he began losing things around the house and getting lost when out walking
  • Daughter feels he was more irritable and his speech was less fluent
  • On warfarin for atrial fibrillation and no history of head injury or focal neurology on examination
A
  • Gyri on left frontotemporal region (right of image) separated from skull by hypodense material. This is clotted blood. Patient has chronic subdural haematoma.
  • Neurosurgical consultation advised. In acute subdural haematoma, fresh blood may appear hyperdense. In sub-acute may appear isodense, making radiological diagnosis difficult.
22
Q

How would subcortical vascular dementia present?

A
  • Often one of gradual deterioration in executive function, as well as mood changes such as apathy or irritability.
  • Memory is often relatively spared and reflects the preservation of cortical grey matter.
  • The patient may additionally have neurological features such as falls, incontinence or seizures.
23
Q

What drugs are used for SDAT (senile dementia alzheimer type)?

A
  • Acetylcholinesterase Inhibitors (AChI) for mild to moderate: –donepezil, rivastigmine, galantamine
  • Memantine for moderate to severe
  • Antipsychotics (eg. risperidone, quetiapine, amisulpride)
  • Antidepressants (eg. mirtazapine, sertraline)
  • Anxiolytics (eg. lorazepam)
  • Hypnotics (eg. zolpidem, zopiclone, clonazepam)
  • Anticonvulsants (eg. valproate, carbamazepine
24
Q

How do cholinesterase inhibitors function? But what are the side effects?

A
  • Improve cognitive function
  • Slow decline
  • Improve non cognitive symptoms
    • ADL
    • Longer at home
    • Reduce carer stress

Side effects

  • Nausea, vomiting, diarrhoea
  • Fatigue, insomnia
  • Muscle cramps
  • Headaches, dizziness
  • Syncope
  • Breathing problems
25
Q

How do we effectively prescribe neuroepileptics?

A
  • –Start low and go slow
  • –Review and stop
  • –Discuss risks
26
Q

What are abilities relating to competance?

A

–Understanding

–Manipulating

–Approaching the situation and its consequences

–Communicating choices

27
Q

What actions can someone with capacity do?

A
  • Act
  • Make
  • Communicate
  • Understand
  • Retain memory of
28
Q

What are the roles of power of attorney?

A
  • Finance
    • Usually easier to retain capacity re granting this than for welfare
  • Welfare
    • Big issues re powers to have you reside
  • Are the powers even being used?
  • Does it have to be ‘activated’
    • Common sense i.e. ‘best interests’
    • letter
  • Are the powers being misused?
  • Who has the powers?
  • Who doesn’t have the powers?
  • Revocation of power of attorney
  • Public Guardian’s Office
29
Q

What is the role and extent of a guardian?

A
  • Finance
  • Welfare
  • They lack capacity to grant poa
  • Two medical certificates
    • GP
    • Psychiatrist
  • Detailed report from MHO (social worker)
    • Will take into account family and those nominated in the application
    • Is it needed?
    • Is it agreed?
    • Who will be the guardian?
30
Q

What are some notable aspects of suicide in the elderly?

A
  • 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
31
Q

What factors could cause suicide in the elderly?

A
  • loneliness
  • widowed
  • ill health
  • chronic pain
  • recent life events
  • few seeing psychiatrist
32
Q

What factors need discussed in relation to cars and dementia?

A
  • notify DVLA at diagnosis of dementia or organic brain syndrome
  • if early dementia license may be yearly
  • “those with poor short term memory, disorientation or lack of insight should almost certainly not drive”
33
Q

How can we avoid dementia?

A
  • Choose your parents
  • Activity
  • Caffeine - avoid
  • Alcohol - avoid
  • HRT - avoid
  • Statins - avoid
  • Hypertension - avoid
  • Good nutrition
  • Fish oils
  • Vitamins

Psychiatry (24 decks)

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