Old Age Psych Flashcards
In which age groups are dementias most prevalent?
80-99
In a 500 bed general hospital how many beds are likely to be taken up by old peeps?
66%
Of the 66% of oldies how many (roughly) are likely to have delirium, dementia and depression?
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.
What is the ABCD of dementia (clinical syndrome)?
- A for Acitivities of Daily Living (ADLs)
- B for Behavioural and Psychiatric Symptoms of Dementia (BPSD)
- C for Cognitive Impairment
- D for Decline
What are 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
- Functional decline
- ADLs
What do MMSE scores correlate to?
correlate with ability to perform daily activities
What are common neuropsychiatric disturbances?
- Psychosis
- Depression
- Altered circadian rhythm
- Agitation
- Anxiety
What is the approach to diagnosing alzheimers disease in primary care?
- Case finding: symptoms suggestings cognitive impairment
- Clinical assessment: history and collateral history, Mental state examination, Physical and bloods, Cognitive assessment
- DDx: exlude delirium, depression
- Specialist Referral: *confirm diagnosis, brain scanning, neuropsychology, *patient and caregiver counselling, *Mx and symptomatic treatment, * follow up
Please explain the differences between delirium and dementia:
Please explain the differences between dementia and depression:
In what ways can we assess, or rather, what tools can we use to assess someones cognition?
MMSE
MOCA (hmmm tasty, 10/10 Kilau)
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?
- Alzheimer’s disease
- Order MRI and look at coronal planes - best view to assess atrophy in the the medial temporal lobes
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?
- 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
How does normal compare with alzheimers with frontotemporal dementia on SPECT?
What are the features and SSx of dementia with Lewy Bodies?
- Dementia. Amnesia not prominent.
- Deficits of attention, frontal executive, visuospatial
- Dx less likely if stroke disease or other brain/systemic illness.
What is the criteria for dementia with lewy bodies?
- Two = probable, One = possible
- a. Fluctuation - marked, important feature
- b. Visual hallucinations
- c. Parkinsonism
- Suggestive - REM sleep disorder, severe antipsych sensitivity, abnormal DAT scan
Which investigation would you order for Dementia with Lewy bodies and what would be seen?
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
What are features/SSx of frontotemporal dementia?
- 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
What are the neuropsychological effects of frontotemporal dementia?
- Neuropsychology - frontal dysexecutive syndrome. Memory, praxis and visuospatial function not severely impaired
What would be seen on imaging for frontotemporal dementia?
Neuroimaging - abnormalities in frontotemporal lobes
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
- 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.
How would subcortical vascular dementia present?
- 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.
What drugs are used for SDAT (senile dementia alzheimer type)?
- 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
How do cholinesterase inhibitors function? But what are the side effects?
- 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
