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Psychiatry > Old Age Psych > Flashcards

Old Age Psych Flashcards

1
Q

3 main conditions encountered in Old Age Psych

A

Delirium
Dementia
Depression

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2
Q

2 Aspects of Dementia

A

Cognitive Features

Neuropsychiatric

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3
Q

Cognitive features in diagnosis of dementia

A 
Memory loss - Dysemnesia
\+ 1 or more of
Dyspraxia
Dysphasia
Dysnosia
Dysexecutive functioning

Functional decline - ADLs

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4
Q

How to investigate cognitive features of dementia?

A

Mini Mental State Examination

MOCA

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5
Q

5 features of Neuropsychiatric disturbance in Dementia

A 
Depression
Psychosis
Altered circadian rhythm - sundowning
Agitation
Anxiety
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6
Q

What elements can be adjusted/investigated when targeting change in behaviour known as sundowning in dementia?

A

Routine
Lighting
Distraction techniques
Sleep

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7
Q

Aetiology of Dementia

A

Alzheimer’s
Vascular dementia
Mixed alzheimer’s and vascular
Lewy Body

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8
Q

Average course from symptoms progressing to death in dementia

A

7 years

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9
Q

Investigations required to diagnose dementia

A

Symptoms showing cognitive impairment
Clinical assessment - History, Collateral history, examination, MSE
Physical examination and bloods
Cognitive assessment - MMSE, MOCA
Differentials - B12, foate, hyperthyroid
Eclude delirium, depression
Referral - confirm diagnosis - brain scanning, neuropsychology

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10
Q

Management of dementia diagnosis

A

Patient and caregiver counselling
Management and symptomatic treatment
Follow-up

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11
Q

What imaging techniques can be used in diagnosis of dementia?

A

MRI
CT
SPECT

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12
Q

Which investigation is poorly tolerated in elderly?

A

MRI

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13
Q

What sign of dementia is present on MRI?

A

Atrophy of mediotemporal lobes

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14
Q

Signs of Alzheimers on SPECT

A

Parietal and temporal areas blue

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15
Q

Signs of Frontotemporal dementia on SPECT

A

Blue areas in frontal and temporal lobes - reduced blood flow

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16
Q

Lewy Body dementia - differences from alzheimers

A

Memory not affected
Deficit of attention
Fluctuation, visual hallucinations, parkinsonism
REM sleep disorder, severe antipsychotic sensitivity
Abnormal DAT
Falls, syncope, loss of consciousness, autonomic impairment
Less likely diagnosis if stroke

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17
Q

Investigation for lewy body dementia

A

DAT
Normal reuptake of dopamine transporter in head of caudate nucleus - comma sign (present in AD)
In Lewy Body, reuptake in putamen reduced - gives full stop sign

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18
Q

Signs of frontotemporal dementia

A 
Emotional blunting
Speech disorder - echolalia, output, stereotypy, preservation, mutism
Frontal dysexecutive syndrome
Parkinsonism signs present later
Autonomic, incontinence
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19
Q

Drug treatment for dementia

A 
Acetylcholinesterase inhibitors
Antidepressants - sertraline, mirtazipine
Antipsychotics - risperidone, quetiapine
Anxiolytics - lorazepam
Hypnotics
Anticonvulsants
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20
Q

Which ACIs are used in mild to moderated AD?

A

Donepezil
Rivastigimine
Galantamine

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21
Q

Which AChIs are used for moderate to severe AD?

A

Memantine

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22
Q

Side effects of cholinesterase inhibitors

A

Nausea, vomiting, diarrhoea

Dizziness, headaches, fatigue, muslce cramps, syncope, breathing problems

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23
Q

Factors that cna help prevent dementia

A 
Activity
Caffeine
Alcohol
HRT
Statins
Hypertension
NSAIDs
Good nutrition
Fish oil
Vitamins
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24
Q

Rarer causes of dementia

A

CJD
Huntington’s
Pick’s disease
HIV

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25
Q

What percentage of AIDS patients will develop dementia?

A

50%

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26
Q

Differentials to dementia

A 
Hypothyroidism, Addison's
B12/folate/thiamine deficiency
Syphilis
Brain tumour
Normal pressure hydrocephalus
Subdural haematoma
Depression
Chronic drug use - alcohol, barbituates
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27
Q

Main types of Vascular dementia

A

Stroke related
Subcortical
Mixed

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28
Q

Risk factors for vascular dementia

A 
Stroke
Smoking
Hypertension
Atrial fibrillation
Obersity
Coronary Artery Disease
Diabetes mellitus
Hyperlipidaemia
A cardiovascular or stroke family history
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29
Q

Typical presentation of vascular dementia

A 
STEPWISE DETERIORATION
Focal neurological abnormalities e.g. visual disturbance, sensory or motor symptoms
The difficulty with attention and concentration
Seizures
Memory disturbance
Gait disturbance
Speech disturbance
Emotional disturbance
30
Q

Which criteria is used to diagnose Vascular dementia?

A

NINDS-AIREN criteria for probable vascular dementia

31
Q

What is the NINDS-AIREN criteria?

A

Recommended by NICE for diagnosis of Vascular dementia

  1. Presence of cognitive decline that interferes with activities of daily living, not due to secondary effects of the cerebrovascular event
    - established using clinical examination and neuropsychological testing
  2. Cerebrovascular disease defined by neurological signs and/or brain imaging
  3. A relationship between the above two disorders inferred by:
    the onset of dementia within three months following a recognised stroke
    an abrupt deterioration in cognitive functions
    fluctuating, stepwise progression of cognitive deficits
32
Q

What is the pathological feature of lewy body dementia?

A

alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas.

33
Q

What feature in a history could indicate lewy body dementia?

A

Deterioration following antipsychotic treatment

34
Q

Which medication should be avoided in patients with lewy body dementia?

A

neuroleptics should be avoided in Lewy body dementia as patients are extremely sensitive and may develop irreversible parkinsonism

35
Q

Symptoms of Pick’s disease

A 
Change in personality
Impaired social conduct
Hyperorality
Disinhibition
Decreased appetite
36
Q

Microscopic changes in pick’s disease

A

Pick bodies - spherical aggregations of tau protein (silver-staining)
Gliosis
Neurofibrillary tangles
Senile plaques

37
Q

In which patients is doneprezil contraindicated?

A

Bradycardia

Adverse effect includes insomnia

38
Q

Classic features of normal hydrocephalus

A

Triad
urinary incontinence
dementia and bradyphrenia
gait abnormality (may be similar to Parkinson’s disease)

39
Q

Name a reversible consequence of dementia

A

Normal hydrocephalus

40
Q

Findings on imaging in normal hydrocephalus

A

hydrocephalus with an enlarged fourth ventricle

in addition to the ventriculomegaly there is typically an absence of substantial sulcal atrophy

41
Q

Management of normal hydrocephalus

A

Ventricuoloperitoneal shunting

42
Q

Complications of ventriculoperitoneal shunting

A

Seziures
Intracerebral Haemorrhage
Infection

43
Q

What deficiency gives rise to Pellagra?

A

Nictonic acid (NIACIN)

44
Q

3 Classical feautres of Pellagra

A

Dementia, diarrhoea, dermatitis

45
Q

What medical treatment can cause pellagra?

A

Isoniazids - inhibits conversion of tryptophan to niacin

46
Q

Which patient population is at risk of pellagra?

A

Alcoholics

47
Q

Describe the type of rash classical of pellagra?

A

(brown scaly rash on sun-exposed sites - termed Casal’s necklace if around neck)

48
Q

Classic triad of parkinson’s symptoms

A

bradykinesia, tremor and rigidity

49
Q

Other features of parkinsons

A 
mask-like facies
flexed posture
micrographia
drooling of saliva
psychiatric features: depression is the most common feature (affects about 40%); dementia, psychosis and sleep disturbances may also occur
impaired olfaction
REM sleep behaviour disorder
fatigue
autonomic dysfunction:
postural hypotension
50
Q

What is the mode of inheritance of Wilson’s disease?

A

Autosomal recessive

51
Q

What is Wilson’s disease?

A

Autosomal recessive condition whereby there are excess copper deposits in tissues
Increased copper absorption in small intestine
Decreased excretion by liver

52
Q

Which gene is implicated in Wilson’s disease

A

ATP7B Chr 13

53
Q

When does onset of Wilson’s disease occur?

A

10-25 years

54
Q

How does the presentation of symptoms in Wilson’s disease differ between children and young adults?

A

Children - liver disease

Adults - neurological disease

55
Q

Features of Wilson’s disease

A 
Hepatitis, cirrhosis
Basal ganglia degeneration
Speech behavioural and psychiatric problems
Asterixis, chorea, parkinsonism
Kayer-Fleishcher rings
Renal tubular acidosis - Fanconi syndrome
Haemolysis
Blue nails
56
Q

What are Kayer-Fleischer rings?

A

Green brown rings in the iris in Wilson’s disease

57
Q

Where is copper mostly deposited in the brain?

A

Basal ganglia

- putamen and globus pallidus

58
Q

Diagnosis of Wilson’s disease

A 
Slit lamp
Reduced serum caeruloplasmin
Reduced total serum copper
Free copper is increased
Increased 24 hour urinary copper
59
Q

Management of Wilson’s disease

A

penicillamine (chelates copper) has been the traditional first-line treatment
trientine hydrochloride is an alternative chelating agent which may become first-line treatment in the future
tetrathiomolybdate

60
Q

Tropheryma whippelii infection causes?

A

Whipple disease

- gives rise to dementia

61
Q

Features of Whipple’s disease

A

malabsorption: diarrhoea, weight loss
large-joint arthralgia
lymphadenopathy
skin: hyperpigmentation and photosensitivity
pleurisy, pericarditis
neurological symptoms (rare): ophthalmoplegia, dementia, seizures, ataxia, myoclonus

62
Q

Investigation of Whipple’s disease?

A

jejunal biopsy shows deposition of macrophages containing Periodic acid-Schiff (PAS) granules

63
Q

Management of Whipple’s disease

A

oral co-trimoxazole for a year is thought to have the lowest relapse rate, sometimes preceded by a course of IV penicillin

64
Q

Features of Creutzfeldt-Jakob disease (CJD

A

Dementia - rapid onset

Myoclonus

65
Q

CJD is caused by?

A

Prion proteins

induce the formation of amyloid folds resulting in tightly packed beta-pleated sheets resistant to proteases.

66
Q

Investigation for CJD

A

CSF is usually normal
EEG: biphasic, high amplitude sharp waves (only in sporadic CJD)
MRI: hyperintense signals in the basal ganglia and thalamus

67
Q

Mode of inheritance in Alzheimer’s

A

Only 5% inherited - Autosomal dominant

68
Q

Risk factor for inherited Alzheimer’s

A

Downs Syndrome

69
Q

Genes implicated in inherited Alzheimer’s

A

Amyloid Precursor Protein chr 21

Presenilin 1 and 2 (chr 14, chr 1)

70
Q

Function of tau protein

A

interacts with tubulin to stabilize microtubules and promote tubulin assembly into microtubules

71
Q

8 causes of tremor

A 
Parkinsonism
Essential tremor
Anxiety
THyrotoxicosis
Hepatic encephalopathy
Carbon dioxide retention
Cerebellar disease
Drug withdrawal - alcohol, opiates

Psychiatry (6 decks)

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