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y3 - psychiatry > old age psychiatry > Flashcards

old age psychiatry Flashcards

1
Q

prevalence of major mental illness in the older population

A

older = >65y/o

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2
Q

impact of major mental illness in older adults

A

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

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3
Q

ABCD of dementia - clinical syndrome

A

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

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4
Q

what is required for a diagnosis of dementia

A

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

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5
Q

cognitive features of dementia

A

memory (dysmnesia) plus one or more of:

  • dysphasia (expressive/receptive)
  • dyspraxia
  • dysgnosia
  • dysexecutive functioning
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6
Q

what is dyspraxia

A

inability to carry out motor skills

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7
Q

what is dysgnosia

A

not recognising objects

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8
Q

what is dysexecutive functioning

A

initiation
inhibition
set-shifting
abstraction

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9
Q

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

A

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

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10
Q

dementia (or organic brain syndrome) and fitness to drive

A

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

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11
Q

how do we do cognitive testing

A

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)

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12
Q

how useful are MMSE scores

A

MMSE scores correlate w/ ability to perform daily activities

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13
Q

what to consider re. imaging for dementia

A

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

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14
Q

diagnosing alzheimer’s disease in 1y care

A
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15
Q

aetiology of dementia - most common types

A

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

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16
Q

aetiology of dementia - rarer types

A

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
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17
Q

aetiology of dementia - reversible causes

A

need to rule out before diagnosing dementia

delirium 
normal pressure hydrocephalus 
subdural haemorrhage 
tumours
vit B12 deficiency 
hypothyroidism 
hypercalcaemia 
alcohol misuse
neurosyphilis 
drugs
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18
Q

triad of symptoms in normal pressure hydrocephalus

A

memory changes, urinary difficulties, gait disturbance

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19
Q

course of dementia

A

time length varies with each patient

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

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20
Q

what is alzheimer’s disease

A

early impairment of memory and executive function

gradual progression w/ often uncelar onset

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21
Q

what are the main features of AD

A

amyloid plaques and tau tangles

atrophy following neurone death

reduction in acetylcholine

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22
Q

risk of AD

A

increases w/ age

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

doubles every 5yrs

40% of those 85y/o

23
Q

SPECT scans

A

most commonly used scan for AD

blue = less perfusion, less activity

24
Q

typical presentation of vascular dementia

A

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

25
Q

key features of Lewy body dementia

A

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

26
Q

supportive features in Lewy body dementia

A

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

27
Q

what is used to diagnose Lewy body dementia

A

DIAMOND

used for pts and carers also

28
Q

DAT scan in DLB

A

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

29
Q

features of FTD

A

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

30
Q

behavioural and psychological symptoms in depression

A

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

31
Q

drug treatment of dementia

A

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

32
Q

ACh inhibitors

A

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

33
Q

side effects of ACh inhibitors

A 
N+V, diarrhoea
fatigue, insomnia 
muscle cramps
headaches, dizziness
syncope
breathing problems

ECG prior to starting

34
Q

examples of ACh inhibitors

A

donezapil
galantamine
rivastigmine

35
Q

risk associated w/ antipsychotic use in dementia

A

stroke

death

36
Q

guidance on antipsychotic use

A

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

37
Q

non-pharmacological approaches to distress

A 
consider other causes
knowing the patient 
ABC approach 
communication - w/ pt and family
any form of distraction
38
Q

prevalence of dementia in care homes

A

3/4 of redsidents have dementia

1/3 of people w/ dementia live in care homes

39
Q

issues in nursing homes

A

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

40
Q

6Cs of capacity

A 
capacity 
consent
compliance
coercion
certification
common sense
41
Q

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

A

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

42
Q

prevalence of depression in the elderly

A

15% have symptoms in the community
3% have illness

F:M 1.5:1

20-30% in residential care

43
Q

clinical features of depression in the elderly

A

less:
depressed mood
expressed suicidal wishes

more: 
insomnia 
hypochondriasis 
suicide
agitation
44
Q

aetiology of depression in the elderly

A 
loss: 
health 
wealth 
spouse
work 
home

genetic

45
Q

management of depression in the elderly

A

antidepressants - NB TCAs side effects
CBT
ECT in severe cases

need for prophylaxis

most community cases not treated

46
Q

prognosis of depression in the elderly

A

mortality x2

25% chronic

better w/ treatment

47
Q

normal grief, mourning and bereavement

A 
alarm 
numbness
pining - illusions or hallucinations may occur
depression 
recovery and reorganisation
48
Q

abnormal grief, mourning and bereavement

A 
persisted >2mths
guilt 
thoughts of death 
worthlessness
psychomotor retardation
prolonged and marked functional impairment
psychosis
49
Q

suicide rate in the elderly

A

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

50
Q

prevalence of late onset sz like psychosis

A

up to 10% of psychiatric admissions in old age

51
Q

clinical features of late onset sz like psychosis

A

spectrum from circumscribed persecutory delusions to full sz like psychosis

52
Q

aetiology of late onset sz like psychosis

A

sensory loss

social isolation

genetic
? minor abnormalities

53
Q

management of late onset sz like psychosis

A

often needs compulsory admission

neuroleptics

increased social contact

54
Q

prognosis of late onset sz like psychosis

A

may fail to regain insight

high relapse if stop neuroleptics

y3 - psychiatry (27 decks)

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