Old age psychiatry Flashcards
What is delirium
Acute, transient, global organic disorder of CNS functioning
Impaired consciousness and attention
What is hypoactive delirium
Lethargy, reduced motor activity, apathy, sleepiness
Most common type of delirium
Can be confused with depression
What is hyperactive delirium
Agitation, irritability, restlessness, aggression
Hallucinations and delusions
Can be confused with functional psychoses
What is the epidemiology of delirium
15-20% of hospital admissions
Most common complication of hospitalisation in the elderly
2/3 have pre-existing dementia
What are the risk factors for delirium
Age >65
Dementia
Renal impairment
Sensory impairment
Recent surgery
Multiple co-morbidities
Physical frailty
Male sex
Previous episode
Severe illness
What is the ICD-10 criteria for delirium
Impairment of consciousness and attention
Global disturbance in cognition
Psychomotor disturbance
Disturbed sleep-wake cycle
Emotional disturbance
What are the clinical features of delirium
Disordered thinking
Euphoric, fearful, depressed, angry
Language impairment
Illusions, delusions, hallucinations
Inattention
Unawareness/disorientation
Memory deficits
Fluctuating course
- Worse at night
What are the investigations for delirium
Urinalysis
Bloods
- FBC, U&Es, LFTs, calcium, glucose, CRP, TFTs, B12, folate, ferritin
ECG
Blood cultures
Questionnaire
What are the differentials for delirium
Dementia
Mood disorders
Late onset schizophrenia
Dissociative disorders
Hyper/hypothyroidism
What is the management for delirium
Treat underlying cause
Reassure and re-orientate
Provide appropriate environment
- Quiet, well-lit room, consistency in staff, encourage family visits
Manage disturbed, violent, or distressed behaviour
- Encourage oral intake, verbal and non-verbal de-escalation techniques, low dose haloperidol/olanzapine (last resort)
What is dementia
Generalised decline in memory, intellect, and personality
No impairment of consciousness
Get functional impairment
What is Alzheimer’s disease
Most common cause of dementia
Degeneration of cholinergic neurons in nucleus basalis
Deficiency in acetylcholine
Microscopic changes
- Neurofibrillary tangle and beta-amyloid plaque formation
Macroscopic changes
- Cortical atrophy, widened sulci, enlarged ventricles
What are the irreversible causes of dementia
Neurodegenerative
- Alzheimer’s, Lewy body, fronto-temporal, Parkinson’s, Huntington’s
Infection
- HIV, encephalopathy, syphilis, CJD
Toxins
- Alcohol, benzodiazepines
Vascular
- Vascular dementia, multi-infarct dementia, CVD
Traumatic head injury
What are the reversible causes of dementia
Neurological
- Normal pressure hydrocephalus, intracranial tumours, chronic subdural haematoma
Vitamin deficiencies
- B12, folic acid, thiamine, nicotinic acid
Endocrine
- Cushing’s, hypothyroidism
What are the risk factors for dementia
Advancing age
Family history
Genetics
Down’s syndrome
Low IQ
Cerebrovascular disease
Vascular risk factors
What are the clinical features of Alzheimer’s disease
Early stage
- Memory lapses, difficulty finding words, forgetting names
Disease progression
- Apraxia, confusion, language problems, difficulty with executive thinking
Late stage
- Disorientation in time and place, wandering apathy, incontinence, eating problems, depression, agitation
Usually in >65s
May have hallucinations or delusions
What are the clinical features of vascular dementia
60-70s
Stepwise deterioration
Memory loss
Depression, apathy, personality changes
Confusion
Upper motor neurone signs
What is mixed dementia
Features of Alzheimer’s disease and vascular dementia
What are the clinical features of Lewy bodies dementia
Day to day fluctuations
Visual hallucinations
Motor signs of Parkinson’s
- Tremor, rigidity, bradykinesia
Recurrent falls, syncope, depression
Dementia and Parkinson’s diagnosed within 12 months of each other
What are the clinical features of fronto-temporal dementia
50-60s
Family history
Early personality changes
- Disinhibition, apathy, restlessness
Worsening social behaviour
Repetitive behaviour
Language problems
Memory preserved in early stages
What are the investigations for dementia
Bloods
- FBC, CRP, U&Es, calcium, LFTs, glucose, B12, folate, TFTs
Urine dip
HIV/syphilis testing
CT/MRI brain
ECG
EEG
Lumbar puncture
Genetic testing
Cognitive assessment
What are the differentials for dementia
Normal ageing and mild cognitive impairment
Delirium
Trauma
Depression
Late onset schizophrenia
Amnesic syndrome
Learning disability
Substance misuse
Drug side effects
What is the non-pharmacological management for dementia
Promote independence
Maintain function
Treat symptoms
Social support
Education
Community dementia teams
Home nursing/personal care
What is the pharmacological management for dementia
Acetylcholinesterase inhibitors
- Donepezil, galantamine, rivastigmine
Memantine
- NMDA receptor antagonist
Antipsychotics
Antidepressants
