Old Age Psychiatry Flashcards
What is delirium?
Also known as ‘acute confusional state’
Acute (hr-d onset), fluctuating syndrome of disturbed:
Consciousness
Attention
Cognition
Perception
What is the ICD-10 criteria for the diagnosis of delirium?
Impairment of consciousness and attention Global disturbance in cognition Psychomotor disturbance Disturbance of sleep-wake cycle Emotional disturbances
Describe the illness course of delirium
Sudden onset
Fluctuating course
Gradual resolution: up to 6-months
Following effective treatment of underlying cause
List the three clinical presentations of delirium
Hyperactive delirium
Hypoactive delirium
Mixed delirium
Describe hyperactive delirium
Psychomotor agitation Increased arousal Inappropriate behaviour Hallucinations: commonly visual Delusions: commonly persecutory Restlessness and wandering are common
Describe hypoactive delirium
Psychomotor retardation Appear quiet or withdrawn Lethargy Reduced appetite Excess somnolence (drowsiness)
Describe mixed delirium
Combination of hyperactive and hypoactive delirium with varying presentation over time
Name three predisposing factors for delirium
Elderly or very young
Pre-existing dementia
Sensory impairment: eg. visual or hearing
Post-op (especially cardiac)
Alcohol abuse; benzodiazepine-dependent; poor nutrition
Serious and/or multiple illnesses; polypharmacy
Lack of stimulation
Provide five precipitating factors for delirium
Delrium is usually multifactorial
UTI; chest infections; infected pressure sore; sepsis
Hyperglycaemia; hypoglycaemia; electrolyte abnormalities
MI; heart failure; stroke; intracranial bleed
Thyroid dysfunction; PE; COPD exacervation
Urinary retention; constipation; malnutrition
Severe uncontrolled pain; major surgery
Medication changes; alcohol intoxication or withdrawal
eg. opiods; benzodiazepines; steroids
Hospital admission; emotional stress; sleep deprivation
Name five complications of delirium
High mortality (20% during admission, up to 50% at 1yr) Increased duration of stay Nosocomial infections Institutionalisation and/or re-admission Increased risk of: Dementia Falls Pressure sores Continence problems Functional impairment; distress for self/carers
What is the association between delirium and dementia?
Delirium causes neuronal death ➔ Independent cause (3x more likely) for dementia development and progression
Pre-existing dementia is a predisposing factor for delirium
Request three investigations for suspected delirium
Cognitive testing: 4AT; MoCA; Addenbrooke's Urinalysis Sputum culture; CXR FBC; CRP U+Es; calcium HbA1c TFTs Haematinics: eg. B12; folate EEG
What are the management principles for delirium
Identify and treat underlying causes
Environmental and supportive measures
Avoid sedation unless severely agitated or a risk
Regular clinical review and follow-up
Name four environmental and supportive measures in the management of delirium
Maintain hydration and nutrition Physical environment eg. Safe environment; good lighting; noise reduction; clocks and calendars; hearing and visual aids Human environment eg. Same staff; firm clear communication; routine; prevent transfer Control of distressing physical symptoms Avoid unnecessary procedures Promote healthy sleep patterns
Name three physical environmental factors for optimal management of delirium
Safe environment Adequate lighting Noise reduction Clocks and calendars If appropriate, hearing and visual aids
Name two human environmental factors for optimal management of delirium
Same group of staff Firm clear communication Routine Prevent transfer Education for those interacting with patient
Outline the managment of a person with delirium who is distressed or considered a risk to themselves or others?
Verbal and non-verbal de-escalation
Short-term haloperidol
Lowest clinically appropriate dose; titrate to symptoms
Use with caution or none if Parkinson’s or Lewy body
Differentiate dementia from delirium
Delirium has altered consciousness and attention
Dementia:
Gradual onset (months to years); progressive deterioration
Normal consciousness; perceptional disturbances occur later
Normal sleep-wake cycle
Delirium:
Acute onset (hours to weeks); fluctuating course
Impaired consciousness; perceptional disturbances common
Disrupted sleep-wake cycle
Disordered thinking, language impairment, inattention
Euphoric, fearful, depressed or angry
What physical examination should be performed in delirium?
ABC Conscious level with AVPU or GCS Vital signs - o2, pulse, BP, temp, capillary blood glucose Nutritional and hydration status CV exam Respiratory exam Abdominal exam - check for urinary retention and rectal exam for faecal impaction Neurological exam including speech
What are the differentials for delirium?
Dementia Mood disorders Late onset schizophrenia Dissociative disorders Hypothyroidism and hyperthyroidism
What is the general management of delirium?
Treat underlying cause
Stop any potential offending drugs, laxatives or catheter if needed
Reassurance and re-orientation
Provide appropriate environment, quiet, well-lit side room, reassurance, family or friend
Manage any disturbed or stress behaviour, low dose haloperidol or olanzapine
Avoid benzos unless delirium is due to alcohol withdrawal
What is paraphrenia?
Paranoid delusions with or without hallucinations, but without the deterioration of intellect or personality.
Patients remain well orientated to time and space.
What is an encapsulated delusion?
An unshakeable belief in something for which there is no evidence nor common acceptance. Occurs in the absence of other signs of psychiatric illness.
What is dementia?
A syndrome of generalised decline of memory, intellect and personality, without impairment of consciousness.
Leads to functional impairment.
What are the microscopic changes in dementia?
Neurofibrillary tangles and beta amyloid plaques.
What are the macroscopic changes in dementia?
Cortical atrophy, widened sulci and enlarged ventricles.
What are the irreversible causes of dementia?
Neurodegenerative - different types of dementia
Infections - HIV, encephalitis, syphilis, CJD
Toxins - alcohol, barbiturates, benzos
Vascular - vascular dementia, multi-infart dementia, CVD
Traumatic head injury
What are the reversible causes of dementia?
Neurological - normal pressure hydrocephalus, intracranial tumours, chronic subdural haematoma
Vitamin deficiencies
Endocrine - cushing’s, hypothyroid
What are the risk factors for Alzheimer’s?
Advancing age
Family history 25-50%
Genetics
Down’s
Low IQ
Cerebrovascular disease - can co-exist with AD
Vascular risk factors - past stroke/MI, smoking, HTN, diabetes and high cholesterol.
What is the ICD-10 classification of dementia?
A. Evidence of
- decline in memory - evident in learning of new info
- decline in other cognitive abilities, deterioration in judgement and thinking
B. preserved awareness of the environment for a period long enough to demonstrate A
C. decline in emotional control or motivation, or change in social behaviour e.g. emotional lability, irritability, apathy, coarsening of social behaviour.
A present for at least 6 months
What are the clinical features of Alzheimer’s?
Loss of memory, initially inability to recall then long term memory.
Disorientation to time and place
Impairment of cognitive and executive functions, executive functions; problem solving, abstract thinking, reasoning
Visuospatial - lost, bad driving
Language disturbances
Apraxia
Agnosia - impaired recognition of sensory stimuli
Non cognitive symptoms - hallucinations, thought creation, behaviour
What is the ICD-10 criteria for Alzheimer’s?
General criteria for dementia must be met, no evidence for any other cause
Early onset - <65, rapid onset and progressive, memory impairment, aphasia or apraxia, inability to read or acalculia
Late onset - general criteria, >65, slow gradual onset, predominance of memory impairment over intellectual impairment.
What are the clinical features of vascular dementia?
Stepwise deterioration Memory loss Emotional - depression, and personality changes earlier than memory loss. Confusion Neurological signs or symptoms
Can be mixed and also have features of Alzheimer’s
What are the features of dementia with lewy bodies?
day to day fluctuations
recurrent visual hallucinations
motor signs of parkinsonism - tremor, rigidity, bradykinesia
Recurrent falls, syncope
depression
those with parkison’s with dementia after 12 months = parkinson’s with dementia, within 12 months of one another = DWLB
What are the symptoms of frontotemporal dementia?
Usually between age 50-60
FH common
Disinhibition, apathy, restlessness, worsening of social behaviour
Repetitive behaviour
Language problems - difficulty to find words, problems naming
Memory is preserved in early stages, but insight lost
What is seen in Huntington’s?
Autosomal dominant so strong family history
Abnormal choreiform movements of hands, face, shoulders, gait abnormalities
Dementia presents later
What is seen in normal pressure hydrocephalus?
Average age of onset after 70
Triad of dementia with prominent frontal lobe dysfunction, urinary incontinence and gait disturbance
What is seen in CJD?
Onset before 65
Rapid progression, death within 2 years
Disintegration of higher cerebral functions
Dementia with neurological signs
What areas of impairment in dementia should be explored in an OSCE?
My Cat Loves Eating Pigeons
Memory Cognition Language Executive functioning Personality
What is seen in dementia in a MSE?
Appearance and Behaviour: may be unkept, inappropriate behaviour, uncoordination, restless
Speech: slow, confused, wrong words, repetitive
Mood: low or normal
Thought: may have delusions
Perception: hallucinations are a core features in DLB, may have illusions
Cognition: memory impairment, impaired attention, disorientation
Insight: may be preserved initially
What are the investigations for dementia?
If present with memory impairment, refer to memory clinic
Bloods: FBC - infection, anaemia CRP U&Es Calcium - hypercalcaemia LFTs - alcoholic liver disease Glucose, B12, folate, TFTs
Urine dipstick rule out UTI CXR for pneumonia, lung ca Syphilis serology, HIV Brain imaging - early onset, sudden decline, focal CNS signs rule out SOL CT, MRI
ECG, EEG
LP if meningitis or CJD
Genetic testing e.g. Huntington’s
Cognitive assessment - MMSE, AMT, ACE Addenbrooke’s, MOCA
What are the differentials for dementia?
Normal ageing, mild cognitive impairment Delirium Trauma; stroke, hypoxic, traumatic brain injury Depression - pseudodementia Late onset schizophrenia Amnesic syndrome Learning distability Substance misuse Drug side effects e.g. opiates, benzos
What are the scores for an MSE?
Normal 25-30
Mild 21-24
Moderate 10-20
Severe <10
What is asked about in the MMSE?
Orientation to time Registration - repeat words back to you Naming Reding Ask to repeat back words
What frontal lobe tests can be done?
Verbal fluency and initiation - recall as many words with the letter e.g. S, aim >15
Cognitive estimates - educated guesses e.g. age of oldest person in the country
Clock drawing - executive function
Similarities - how are objects alike e.g. orange and banana both fruits
Motor sequencing - demonstrate and repeat movements
What is the general management of dementia?
Supportive treatment e.g. OT input home safety
Environmental control measures; motion sensors, call bells
Acetylcholinesterase inhibitors
Contact DVLA
Advanced planning - LPA
Mental Capacity Act
Treat agitation
Treat low mood and insomnia
Functional support, social support
Support for carers
What is the pharmacological management for dementia?
For mild to moderate Alzheimer’s - AChE inhibitors e.g. donepezil
Memantine NMDA receptor antagonist if severe or intolerant to AChE inhibitors
Antipsychotics or antidepressants for behaviour changes
How does AChE inhibitors work?
Centrally acting
Compensate for the depletion of acetylcholine in the cerebral cortex and hippocampus in AD.
What is pseudodementia/Ganser’s syndrome?
A dissociative disorder, very rare
Thought people develop it consciously or subconsciously to avoid an unpleasant situation.
Common to occur on a background of head injury or serious illness
What are the four principal features of pseudodementia?
Approximate answers - incorrect answer but suggests they understand the question
Clouding of consciousness
Somatic conversion symptoms e.g. hysterical paralysis
Hallucinations, visual or auditory
Investigations e.g. bloods, urine drug screen, CT, MRI to rule out any organic causes
What are the risk factors for vascular dementia?
Stroke/TIA HTN AF DM Smoker Hyperlipidaemia
What are the two classifications of vascular dementia?
Stroke related: as a result of cerebrovascular disease
Small vessel related: due to arteriosclerosis
What is lewy body dementia?
Abnormal protein (Lewy bodies) deposition in the substantia nigra and neocortex leading to cholinergic and dopaminergic neurone loss
How is Lewy Body dementia investigated and then managed?
What drugs must be avoided?
DaTscan
- rivastigmine or donepezil
- galantamine
- memantine
Avoid neuroleptics as can induce parkinsonism
What are the types of fronto-temporal dementia? What features are common to all 3?
Picks disease
Chronic progressive aphasia (CPA)
Semantic
All have a gradual onset
Memory is often preserved
Personality changes
No insight
What causes Picks disease and how does it present?
Picks bodies and fronto-temporal atrophy
- disinhibition
- impaired social conduct
- increased appetite
How is depression differentiated from dementia?
Depression has:
- rapid onset
- biological symptoms (Weight loss/sleep disturbance)
- mini mental state test can be variable
- global memory loss (vs dementia more recent)
