Old Age Psychiatry Flashcards by Jess Grace

Define Delirium

Acute transient global organic disorder of CNS resulting in impaired consciousness and attention

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There are three types of delirium. Describe Hypoactive Delirium

Lethargy
Reduced motor activity
Apathy
Sleepiness

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There are three types of delirium. Describe Hyperactive Delirium

Agitated
Aggressive
Hallucinations and Delusions

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What is the third type of Delirium?

Mixed - signs of both

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There are many different causes of Delirium. Using the mnemonic THINk DELIRIUM, describe them

Trauma, Hypoxia, Increased age, NOF fracture, smoKer, Drugs, Environment, Lack of sleep, Imbalanced electrolytes, Retention, Infection, Uncontrolled Pain, Medical Conditions

hypoxia, hypoglycaemia, hyperglycaemia, infection, constipation, urinary retention, intoxication, withdrawl

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Delirium is Acute in onset and fluctuating in course. Using the mnemonic DELIRIUM describe the classical presenting features

Disordered thinking, Euphoric, Language Impaired, Illusions (+/ - delusions or hallucinations), Reversal of sleep wake pattern, Inattention, Unaware (Disorientated), Memory Deficits

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State the five ICD10 requirements for Delirium diagnosis

Impairment of consciousness and attention
Global disturbance in cognition
Psychomotor disturbance
Disturbance of sleep wake cycle
Emotional disturbance

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Name five immediate investigations you would do for a Delirious patient

Nutritional and Hydration Status
Systems Examination
Urinalysis
Bloods - FBC, U&Es, LFTs, calcium, glucose, B12 folate ferritin
ECG
CXR

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Describe the (10) features of an AMT (Abbreviated Mental Test)

Age, Time, (Recall 42 West Street at end), Year, Current Location, Identify two people, DOB, Date of WW1, Current Monarch, Count backwards from 20

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Describe the features of CAM (Confusion Assessment Method)

Diagnosis involves the presence of 1 and 2 and 3/4

1) Acute Onset and Fluctuating Course
2) Inattention (demonstrated by serial 7s test)
3) Disorganised thinking (incoherent speech)
4) Altered consciousness

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The mainstay of Delirium treatment is treating the underlying cause and providing reassurance. How can the patients environment be optimised?

Quiet
Well lit
Consistent staff
Encouraging visitation
Photos and familiar items
Orientate to time and place

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How should the behaviour of Delirious patients be managed?

Medication should be a last resort

Oral low dose Haloperidol or Olanzepine
Avoid Benzodiazepines

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Define Dementia

Generalised decline of memory, intellect and personality without impairment in consciousness leading to functional impairment

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Name 4 irreversible causes of Dementia

Neurodegenerative
Infections (HIV, CJD)
Toxins
Vascular
Traumatic Head Injury

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Name 4 reversible causes of Dementia

Visual/Hearing impairment,
Nutritional Deficiencies
Normal pressure hydrocephalus
Hypothyroidism

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What is Vascular Dementia?

Occurs as a result of Cerebrovascular Disease (stroke, multiple infarcts, or chronic changes such as Atherosclerosis in the small vessels

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What is Lewy Body Dementia?

Abnormal deposition of Lewy Body proteins throughout the neurones in the brainstem, substantia nigra and neocortex

If outside brainstem - more profound cholinergic loss
If within brainstem - more profound dopaminergic loss and Parkinsonian sx

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What is Frontotemporal Dementia?

Atrophy of Frontotemporal Lobes

One type is Picks disease - where proteins tangle and are seen histologically (characterised histologically by Picks Proteins)

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Dementia can be Cortical (such as Alzheimer’s and Frontotemporal). Give four clinical features.

Severe Memory Loss
Normal mood
Early Aphasia
Apraxia
Normal Coordination and motor speed

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Dementia can be Sub-Cortical (such as DLB). Give four clinical features.

Moderate Memory Loss
Low mood
Impaired Coordination
Slow Motor Speed
May have Dysarthria

Give an example of mixed Cortical and Subcortical Dementia

Vascular

Describe the genetic risks for developing Alzheimer’s

Early Onset - Presenilin 1 and 2, Amyloid Precursor Protein
Late Onset - ApoE 4

what are some risk factors for alzheimer’s disease?

advancing age

family hx

genetics

down’s syndrome

low IQ

cerebrovascular disease

vascular risk factors

Describe the ICD10 criteria A-D for Dementia

A - evidence of decline in memory and other cognitive abilities
B - Preserved awareness for long enough to demonstrate A
C - Decline in emotional control/motivation/behaviour (emotional lability, irritability, apathy, coarsening social behaviour)
D - A must be present for 6 months

What are the parameters for Presenile and Senile Dementia?

Presenile is \<65 Senile is \>65

Describe the features of early Alzheimer’s

Memory lapses Difficulty finding words Forgetting names of people/places

Describe the late stages of Alzheimer’s

Disorientation to time and place Apathy Incontinence Agitation

Describe the ICD10 criteria for early onset Alzheimer’s

A - General criteria for Alzheimer’s met and age \<65 B - Atleast one of: relatively rapid onset and progression, aphasia/agraphia/apraxia/alexia

Describe the ICD10 criteria for late onset Alzheimer’s

A - General Alzheimer’s criteria met and age \>65 B - Atleast one of: Slow gradual onset and progression, predominance of memory impairment over intellectual ability

How does Vascular Dementia typically present?

* Late sixties/early seventies * Stepwise deterioration * Confusion * Memory loss * Early personality changes and Emotional * May have signs of cardiovascular disease * may have UMN signs

What is Mixed Dementia?

Features of both Alzheimer’s and Vascular

Name four features of DLB

* Day to day fluctuations in cognitive performance * Recurrent visual hallucinations * Motor signs of Parkinsonism * Recurrent falls, syncope, depression * Severe sensitivity to Neuroleptic drugs

Describe four clinical features of Frontotemporal Dementia

* Usually 50-60 y/o * Worsening of social behaviour * Early personality changes such as disinhibition/apathy/restlessness * Memory is preserved in early stages

How does Huntington’s Disease present?

* Abnormal Choreiform Movements of face hands and shoulders and gait abnormalities * Dementia Symptoms presenting later on Autosomal dominant so strong FH

What is the triad of Normal Pressure Hydrocephalus

Dementia with frontal lobe disturbance Urinary Incontinence Gait disturbance (wide) average age of onset after 70

Describe three features of Creutzfield Jakob Disease

* Onset usually \<65 * Rapid progression and death within 2y * Disintegration of all higher cerebral functions * Dementia associated with neurological signs

How is suspected dementia investigated?

Initially referred to memory clinic Routine panels of bloods- FBC, CRP, U&Es, calcium, LFTs, glucose, vit B12, folate, TFTs

what other non-routine investigations may be done if clinically indicated for dementia?

* urine dip to rule out UTI * CXR * syphilis serology and HIV testing * brain imaging - CT, MRI, SPECT * ECG * EEG * LP * genetic tests * cognitive assessment

What imaging is used to differentiate Alzheimer’s, Vascular and Frontotemporal?

**SPECT** - Single Photon Emission Computed Tomography

what is always important to assess in dementia patients?

functional status - dressing, continence, self-care, shopping/housework, ability to mange financial affairs, social contacts, safety in the home, ability to cook, nutrition

Name four features of the MMSE

Orientation Concentration (Serial 7s) Memory - short term, long term, recent Grasp - name of monarch Normal is 25-30, severe is less than 10

Name three frontal lobe tests

Verbal fluency and initiation Clock drawing tests Similarities (why are two objects similar?)

State two general managements of Dementia

* Inform DVLA * Advanced planning * later stages - Mental Capacity Act 2005 needs to be adhered to

Describe the non pharmacological management of Dementia

* Social Support * Community dementia teams * Information and education * Aromatherapy, massage, animal-assisted therapy * Assistance in day to day activities

One of the pharmacological options to treat Dementia is acetylcholinesterase inhibitors. Given an example, 2 contraindications and 2 side effects

Donepazil, Galantamine and Rivastigmine CI - Renal impairment, Hepatic impairment SE - GI disturbance, Bradycardia, muscle spasms

What is the action of Memantine?

NMDA receptor antagonist used for AD when moderate when intolerant/contraindicated to use AChEi or in severe AD

How could you manage challenging behaviour of Dementia patients?

Short course of antipsychotics antidepressants for low mood Caution in DLB - Neuroleptic Malignant Syndrome

principals of dementia management

dementia v delirium