Old age psychiatry

Question 1

What is delirium

Answer 1

Acute, transient, global organic disorder of CNS functioning

Impaired consciousness and attention

Question 2

What is hypoactive delirium

Answer 2

Lethargy, reduced motor activity, apathy, sleepiness

Most common type of delirium

Can be confused with depression

Question 3

What is hyperactive delirium

Answer 3

Agitation, irritability, restlessness, aggression

Hallucinations and delusions

Can be confused with functional psychoses

Question 4

What is the epidemiology of delirium

Answer 4

15-20% of hospital admissions

Most common complication of hospitalisation in the elderly

2/3 have pre-existing dementia

Question 5

What are the risk factors for delirium

Answer 5

Age >65

Dementia

Renal impairment

Sensory impairment

Recent surgery

Multiple co-morbidities

Physical frailty

Male sex

Previous episode

Severe illness

Question 6

What is the ICD-10 criteria for delirium

Answer 6

Impairment of consciousness and attention

Global disturbance in cognition

Psychomotor disturbance

Disturbed sleep-wake cycle

Emotional disturbance

Question 7

What are the clinical features of delirium

Answer 7

Disordered thinking

Euphoric, fearful, depressed, angry

Language impairment

Illusions, delusions, hallucinations

Inattention

Unawareness/disorientation

Memory deficits

Fluctuating course
- Worse at night

Question 8

What are the investigations for delirium

Answer 8

Urinalysis

Bloods
- FBC, U&Es, LFTs, calcium, glucose, CRP, TFTs, B12, folate, ferritin

ECG

Blood cultures

Questionnaire

Question 9

What are the differentials for delirium

Answer 9

Dementia

Mood disorders

Late onset schizophrenia

Dissociative disorders

Hyper/hypothyroidism

Question 10

What is the management for delirium

Answer 10

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)

Question 11

What is dementia

Answer 11

Generalised decline in memory, intellect, and personality

No impairment of consciousness

Get functional impairment

Question 12

What is Alzheimer’s disease

Answer 12

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

Question 13

What are the irreversible causes of dementia

Answer 13

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

Question 14

What are the reversible causes of dementia

Answer 14

Neurological
- Normal pressure hydrocephalus, intracranial tumours, chronic subdural haematoma

Vitamin deficiencies
- B12, folic acid, thiamine, nicotinic acid

Endocrine
- Cushing’s, hypothyroidism

Question 15

What are the risk factors for dementia

Answer 15

Advancing age

Family history

Genetics

Down’s syndrome

Low IQ

Cerebrovascular disease

Vascular risk factors

Question 16

What are the clinical features of Alzheimer’s disease

Answer 16

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

Question 17

What are the clinical features of vascular dementia

Answer 17

60-70s

Stepwise deterioration

Memory loss

Depression, apathy, personality changes

Confusion

Upper motor neurone signs

Question 18

What is mixed dementia

Answer 18

Features of Alzheimer’s disease and vascular dementia

Question 19

What are the clinical features of Lewy bodies dementia

Answer 19

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

Question 20

What are the clinical features of fronto-temporal dementia

Answer 20

50-60s

Family history

Early personality changes
- Disinhibition, apathy, restlessness

Worsening social behaviour

Repetitive behaviour

Language problems

Memory preserved in early stages

Question 21

What are the investigations for dementia

Answer 21

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

Question 22

What are the differentials for dementia

Answer 22

Normal ageing and mild cognitive impairment

Delirium

Trauma

Depression

Late onset schizophrenia

Amnesic syndrome

Learning disability

Substance misuse

Drug side effects

Question 23

What is the non-pharmacological management for dementia

Answer 23

Promote independence

Maintain function

Treat symptoms

Social support

Education

Community dementia teams

Home nursing/personal care

Question 24

What is the pharmacological management for dementia

Answer 24

Acetylcholinesterase inhibitors
- Donepezil, galantamine, rivastigmine

Memantine
- NMDA receptor antagonist

Antipsychotics

Antidepressants