old age psychiatry

Question 1

prevalence of major mental illness in the older population

Answer 1

older = >65y/o

Question 2

impact of major mental illness in older adults

Answer 2

increased length of hospital stay
increased mortality when in hospital
huge economic cost
cost of increased need for formal and informal carers

Question 3

ABCD of dementia - clinical syndrome

Answer 3

ADLs
Behaviour and psychiatric symptoms of dementia (BPSD)
Cognitive impairment
Decline

Question 4

what is required for a diagnosis of dementia

Answer 4

6mths duration, usually progressive

diagnosis based on hx and collateral

PMH and medication - esp anti-cholinergics

cognitive testing w/ emphasis on relevant lobes

physical examination and bloods

supportive evidence from brain imaging - not required in all pts depending on symptoms

diagnosis deferred in delirium

Question 5

cognitive features of dementia

Answer 5

memory (dysmnesia) plus one or more of:

• dysphasia (expressive/receptive)
• dyspraxia
• dysgnosia
• dysexecutive functioning

Question 6

what is dyspraxia

Answer 6

inability to carry out motor skills

Question 7

what is dysgnosia

Answer 7

not recognising objects

Question 8

what is dysexecutive functioning

Answer 8

initiation
inhibition
set-shifting
abstraction

Question 9

what are important areas to ask about in functional impairment for a diagnosis of dementia

Answer 9

ADLs

basic hygiene

nutrition and hydration - check whether they have been a cook in the past (if they haven’t and there isn’t a change this isn’t an issue)
- consider changes to simpler meals, ready meals, not cooking food properly

remembering to take medication/if they’ve already taken it

driving

bowel function and getting to the toilet

work/caring role

finances

pets

Question 10

dementia (or organic brain syndrome) and fitness to drive

Answer 10

notify DVLA at diagnosis
if early dementia, license may be yearly

those w/ poor STM, disorientation or lack of insight should almost certainly not drive

Question 11

how do we do cognitive testing

Answer 11

MMSE - mini mental state examination

MOCA - montreal cognitive assessment (people tend to score lower on this one)

remember a person’s education and communication may impact their score
- also consider other issues: vision, hearing, inability to draw (parkinson’s, can’t hold pen etc)

Question 12

how useful are MMSE scores

Answer 12

MMSE scores correlate w/ ability to perform daily activities

Question 13

what to consider re. imaging for dementia

Answer 13

consider what is most appropriate for patient

do they need imaging? - sometimes diagnosis is very clear from hx, scanning is less sensitive in >80y/o

CT, CT/SPECT (more specific for alzheimers), DAT scan

Question 14

diagnosing alzheimer’s disease in 1y care

Answer 14

Question 15

aetiology of dementia - most common types

Answer 15

alzheimer’s demetia - 62%
vascular dementia - 17%
mixed dementia - 10%
lewy body dementia - 4% - possibly underdiagnosed

Question 16

aetiology of dementia - rarer types

Answer 16

frontotemporal (picks) - behavioural, PNFA (progressive non fluent aphasia), semantic

alcohol - ARBD, korsakoffs

subcortical - parkinson’s, huntington’s, HIV

prion protein - CJD

• tend to be younger presenting

Question 17

aetiology of dementia - reversible causes

Answer 17

need to rule out before diagnosing dementia

delirium 
normal pressure hydrocephalus 
subdural haemorrhage 
tumours
vit B12 deficiency 
hypothyroidism 
hypercalcaemia 
alcohol misuse
neurosyphilis 
drugs

Question 18

triad of symptoms in normal pressure hydrocephalus

Answer 18

memory changes, urinary difficulties, gait disturbance

Question 19

course of dementia

Answer 19

time length varies with each patient

not all patients end up in nursing homes but most require additional care

Question 20

what is alzheimer’s disease

Answer 20

early impairment of memory and executive function

gradual progression w/ often uncelar onset

Question 21

what are the main features of AD

Answer 21

amyloid plaques and tau tangles

atrophy following neurone death

reduction in acetylcholine

Question 22

risk of AD

Answer 22

increases w/ age

1% 50y/o
5% 65y/o

doubles every 5yrs

40% of those 85y/o

Question 23

SPECT scans

Answer 23

most commonly used scan for AD

blue = less perfusion, less activity

Question 24

typical presentation of vascular dementia

Answer 24

unequal distribution of deficits
evidence of focal impairments on neuro exam
evidence of cerebrovascular disease - PMH
stepwise decline w/ sudden changes

small vessel disease can give gradual decline

Question 25

key features of Lewy body dementia

Answer 25

visual halllucinations - e.g. patterns on the walls, small animals fluctuations parkinsonism

Question 26

supportive features in Lewy body dementia

Answer 26

sensitivity to antipsychotics reduced dopamine uptake DAT scan increased falls REM sleep disorder

Question 27

what is used to diagnose Lewy body dementia

Answer 27

DIAMOND used for pts and carers also

Question 28

DAT scan in DLB

Answer 28

sensitivity and specifficity of ~85% normal/AD - normal reuptake of dopamine transporter in the head to the caudate nucleas and the putamen in a comma shape LB - full stop shape, reduced uptake

Question 29

features of FTD

Answer 29

behavioural disorder - personality change can be early onset early emotional blunting speech disorder - altered output, stereotypy, echolalia, perseveration, mutism neuropsychology - frontal dysexecutive function. Memory, praxis and visuospatial function not severely impaired neuroimaging - abnormalities in frontotemporal lobes neurological signs commonly absent early, Parkinsonism later, MND on a few, autonomic, incontinence, primitive reflexes

Question 30

behavioural and psychological symptoms in depression

Answer 30

agitation - restlessness, waking psychosis - delusions, hallucinations affective - depression, anxiety, lability, hypomania, apathy disinhibition - aggression, sexual behaviour - eating, toileting, dressing, sleep-wake cycle cumulative risk with time? - check this

Question 31

drug treatment of dementia

Answer 31

mild-moderate AD - ACh inhibitors - donepezil, rivastigmine, galantamine (slow down symptoms) mod-severe AD - memantine (slow down symptoms) antipsychotics - risperidone, quetiapine, amisulpride (controversial) antidepressants - mirtazapine, sertraline anxiolytics - lorazepam hypnotics - zolpidem, zopiclone, clonazepam anticonvulsants - valproate, carbamazepine

Question 32

ACh inhibitors

Answer 32

similar effects on MMSE, ADAS COG improved cognitive function, ADLs and behaviour - small treatment effects delays time to institutionalisation not as useful for vascular dementia

Question 33

side effects of ACh inhibitors

Answer 33

``` N+V, diarrhoea fatigue, insomnia muscle cramps headaches, dizziness syncope breathing problems ``` ECG prior to starting

Question 34

examples of ACh inhibitors

Answer 34

donezapil galantamine rivastigmine

Question 35

risk associated w/ antipsychotic use in dementia

Answer 35

stroke | death

Question 36

guidance on antipsychotic use

Answer 36

not 1st line unless extreme risk detailed assessment of BPSD incl ABC address treatable causes symptoms are primarily a problem for pt or carers high rate of spontaneous recovery w/o medication psychological approaches incl structured activity - distraction when agitated, can be very successful discussion re best interests lowest dose of atypical for shorted time - ideally <12wks mthly review recommended

Question 37

non-pharmacological approaches to distress

Answer 37

``` consider other causes knowing the patient ABC approach communication - w/ pt and family any form of distraction ```

Question 38

prevalence of dementia in care homes

Answer 38

3/4 of redsidents have dementia | 1/3 of people w/ dementia live in care homes

Question 39

issues in nursing homes

Answer 39

little continuity of staff lots of BPSD - exacerbates symptoms psychosocial interventions recommended but medication often has to be relied on

Question 40

6Cs of capacity

Answer 40

``` capacity consent compliance coercion certification common sense ```

Question 41

functional illness - what to consider if it isn't dementia

Answer 41

depressive symptoms 15% depressive illness 3% anxiety disorders - GAD, panic disorder, agoraphobia, PTSD ``` BPAD - mania sz late onset sz like psychosis alcohol problems suicide ``` delirium

Question 42

prevalence of depression in the elderly

Answer 42

15% have symptoms in the community 3% have illness F:M 1.5:1 20-30% in residential care

Question 43

clinical features of depression in the elderly

Answer 43

less: depressed mood expressed suicidal wishes ``` more: insomnia hypochondriasis suicide agitation ```

Question 44

aetiology of depression in the elderly

Answer 44

``` loss: health wealth spouse work home ``` genetic

Question 45

management of depression in the elderly

Answer 45

antidepressants - NB TCAs side effects CBT ECT in severe cases need for prophylaxis most community cases not treated

Question 46

prognosis of depression in the elderly

Answer 46

mortality x2 25% chronic better w/ treatment

Question 47

normal grief, mourning and bereavement

Answer 47

``` alarm numbness pining - illusions or hallucinations may occur depression recovery and reorganisation ```

Question 48

abnormal grief, mourning and bereavement

Answer 48

``` persisted >2mths guilt thoughts of death worthlessness psychomotor retardation prolonged and marked functional impairment psychosis ```

Question 49

suicide rate in the elderly

Answer 49

same rate as <25 age group 1/2 the rate of other age groups M>F most are depressed deliberate self harm is rare in the elderly often: loneliness, widowed, ill health, chronic pain, recent life events few seeing psychiatrist

Question 50

prevalence of late onset sz like psychosis

Answer 50

up to 10% of psychiatric admissions in old age

Question 51

clinical features of late onset sz like psychosis

Answer 51

spectrum from circumscribed persecutory delusions to full sz like psychosis

Question 52

aetiology of late onset sz like psychosis

Answer 52

sensory loss social isolation genetic ? minor abnormalities

Question 53

management of late onset sz like psychosis

Answer 53

often needs compulsory admission neuroleptics increased social contact

Question 54

prognosis of late onset sz like psychosis

Answer 54

may fail to regain insight high relapse if stop neuroleptics