Old Age Psych Flashcards
3 main conditions encountered in Old Age Psych
Delirium
Dementia
Depression
2 Aspects of Dementia
Cognitive Features
Neuropsychiatric
Cognitive features in diagnosis of dementia
Memory loss - Dysemnesia \+ 1 or more of Dyspraxia Dysphasia Dysnosia Dysexecutive functioning
Functional decline - ADLs
How to investigate cognitive features of dementia?
Mini Mental State Examination
MOCA
5 features of Neuropsychiatric disturbance in Dementia
Depression Psychosis Altered circadian rhythm - sundowning Agitation Anxiety
What elements can be adjusted/investigated when targeting change in behaviour known as sundowning in dementia?
Routine
Lighting
Distraction techniques
Sleep
Aetiology of Dementia
Alzheimer’s
Vascular dementia
Mixed alzheimer’s and vascular
Lewy Body
Average course from symptoms progressing to death in dementia
7 years
Investigations required to diagnose dementia
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
Management of dementia diagnosis
Patient and caregiver counselling
Management and symptomatic treatment
Follow-up
What imaging techniques can be used in diagnosis of dementia?
MRI
CT
SPECT
Which investigation is poorly tolerated in elderly?
MRI
What sign of dementia is present on MRI?
Atrophy of mediotemporal lobes
Signs of Alzheimers on SPECT
Parietal and temporal areas blue
Signs of Frontotemporal dementia on SPECT
Blue areas in frontal and temporal lobes - reduced blood flow
Lewy Body dementia - differences from alzheimers
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
Investigation for lewy body dementia
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
Signs of frontotemporal dementia
Emotional blunting Speech disorder - echolalia, output, stereotypy, preservation, mutism Frontal dysexecutive syndrome Parkinsonism signs present later Autonomic, incontinence
Drug treatment for dementia
Acetylcholinesterase inhibitors Antidepressants - sertraline, mirtazipine Antipsychotics - risperidone, quetiapine Anxiolytics - lorazepam Hypnotics Anticonvulsants
Which ACIs are used in mild to moderated AD?
Donepezil
Rivastigimine
Galantamine
Which AChIs are used for moderate to severe AD?
Memantine
Side effects of cholinesterase inhibitors
Nausea, vomiting, diarrhoea
Dizziness, headaches, fatigue, muslce cramps, syncope, breathing problems
Factors that cna help prevent dementia
Activity Caffeine Alcohol HRT Statins Hypertension NSAIDs Good nutrition Fish oil Vitamins
Rarer causes of dementia
CJD
Huntington’s
Pick’s disease
HIV
What percentage of AIDS patients will develop dementia?
50%
Differentials to dementia
Hypothyroidism, Addison's B12/folate/thiamine deficiency Syphilis Brain tumour Normal pressure hydrocephalus Subdural haematoma Depression Chronic drug use - alcohol, barbituates
Main types of Vascular dementia
Stroke related
Subcortical
Mixed
Risk factors for vascular dementia
Stroke Smoking Hypertension Atrial fibrillation Obersity Coronary Artery Disease Diabetes mellitus Hyperlipidaemia A cardiovascular or stroke family history
Typical presentation of vascular dementia
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
Which criteria is used to diagnose Vascular dementia?
NINDS-AIREN criteria for probable vascular dementia
What is the NINDS-AIREN criteria?
Recommended by NICE for diagnosis of Vascular dementia
- 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 - Cerebrovascular disease defined by neurological signs and/or brain imaging
- 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
What is the pathological feature of lewy body dementia?
alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas.
What feature in a history could indicate lewy body dementia?
Deterioration following antipsychotic treatment
Which medication should be avoided in patients with lewy body dementia?
neuroleptics should be avoided in Lewy body dementia as patients are extremely sensitive and may develop irreversible parkinsonism
Symptoms of Pick’s disease
Change in personality Impaired social conduct Hyperorality Disinhibition Decreased appetite
Microscopic changes in pick’s disease
Pick bodies - spherical aggregations of tau protein (silver-staining)
Gliosis
Neurofibrillary tangles
Senile plaques
In which patients is doneprezil contraindicated?
Bradycardia
Adverse effect includes insomnia
Classic features of normal hydrocephalus
Triad
urinary incontinence
dementia and bradyphrenia
gait abnormality (may be similar to Parkinson’s disease)
Name a reversible consequence of dementia
Normal hydrocephalus
Findings on imaging in normal hydrocephalus
hydrocephalus with an enlarged fourth ventricle
in addition to the ventriculomegaly there is typically an absence of substantial sulcal atrophy
Management of normal hydrocephalus
Ventricuoloperitoneal shunting
Complications of ventriculoperitoneal shunting
Seziures
Intracerebral Haemorrhage
Infection
What deficiency gives rise to Pellagra?
Nictonic acid (NIACIN)
3 Classical feautres of Pellagra
Dementia, diarrhoea, dermatitis
What medical treatment can cause pellagra?
Isoniazids - inhibits conversion of tryptophan to niacin
Which patient population is at risk of pellagra?
Alcoholics
Describe the type of rash classical of pellagra?
(brown scaly rash on sun-exposed sites - termed Casal’s necklace if around neck)
Classic triad of parkinson’s symptoms
bradykinesia, tremor and rigidity
Other features of parkinsons
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
What is the mode of inheritance of Wilson’s disease?
Autosomal recessive
What is Wilson’s disease?
Autosomal recessive condition whereby there are excess copper deposits in tissues
Increased copper absorption in small intestine
Decreased excretion by liver
Which gene is implicated in Wilson’s disease
ATP7B Chr 13
When does onset of Wilson’s disease occur?
10-25 years
How does the presentation of symptoms in Wilson’s disease differ between children and young adults?
Children - liver disease
Adults - neurological disease
Features of Wilson’s disease
Hepatitis, cirrhosis Basal ganglia degeneration Speech behavioural and psychiatric problems Asterixis, chorea, parkinsonism Kayer-Fleishcher rings Renal tubular acidosis - Fanconi syndrome Haemolysis Blue nails
What are Kayer-Fleischer rings?
Green brown rings in the iris in Wilson’s disease
Where is copper mostly deposited in the brain?
Basal ganglia
- putamen and globus pallidus
Diagnosis of Wilson’s disease
Slit lamp Reduced serum caeruloplasmin Reduced total serum copper Free copper is increased Increased 24 hour urinary copper
Management of Wilson’s disease
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
Tropheryma whippelii infection causes?
Whipple disease
- gives rise to dementia
Features of Whipple’s disease
malabsorption: diarrhoea, weight loss
large-joint arthralgia
lymphadenopathy
skin: hyperpigmentation and photosensitivity
pleurisy, pericarditis
neurological symptoms (rare): ophthalmoplegia, dementia, seizures, ataxia, myoclonus
Investigation of Whipple’s disease?
jejunal biopsy shows deposition of macrophages containing Periodic acid-Schiff (PAS) granules
Management of Whipple’s disease
oral co-trimoxazole for a year is thought to have the lowest relapse rate, sometimes preceded by a course of IV penicillin
Features of Creutzfeldt-Jakob disease (CJD
Dementia - rapid onset
Myoclonus
CJD is caused by?
Prion proteins
induce the formation of amyloid folds resulting in tightly packed beta-pleated sheets resistant to proteases.
Investigation for CJD
CSF is usually normal
EEG: biphasic, high amplitude sharp waves (only in sporadic CJD)
MRI: hyperintense signals in the basal ganglia and thalamus
Mode of inheritance in Alzheimer’s
Only 5% inherited - Autosomal dominant
Risk factor for inherited Alzheimer’s
Downs Syndrome
Genes implicated in inherited Alzheimer’s
Amyloid Precursor Protein chr 21
Presenilin 1 and 2 (chr 14, chr 1)
Function of tau protein
interacts with tubulin to stabilize microtubules and promote tubulin assembly into microtubules
8 causes of tremor
Parkinsonism Essential tremor Anxiety THyrotoxicosis Hepatic encephalopathy Carbon dioxide retention Cerebellar disease Drug withdrawal - alcohol, opiates
