old age psychiatry Flashcards
prevalence of major mental illness in the older population
older = >65y/o
impact of major mental illness in older adults
increased length of hospital stay
increased mortality when in hospital
huge economic cost
cost of increased need for formal and informal carers
ABCD of dementia - clinical syndrome
ADLs
Behaviour and psychiatric symptoms of dementia (BPSD)
Cognitive impairment
Decline
what is required for a diagnosis of dementia
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
cognitive features of dementia
memory (dysmnesia) plus one or more of:
- dysphasia (expressive/receptive)
- dyspraxia
- dysgnosia
- dysexecutive functioning
what is dyspraxia
inability to carry out motor skills
what is dysgnosia
not recognising objects
what is dysexecutive functioning
initiation
inhibition
set-shifting
abstraction
what are important areas to ask about in functional impairment for a diagnosis of dementia
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
dementia (or organic brain syndrome) and fitness to drive
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
how do we do cognitive testing
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)
how useful are MMSE scores
MMSE scores correlate w/ ability to perform daily activities
what to consider re. imaging for dementia
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
diagnosing alzheimer’s disease in 1y care
aetiology of dementia - most common types
alzheimer’s demetia - 62%
vascular dementia - 17%
mixed dementia - 10%
lewy body dementia - 4% - possibly underdiagnosed
aetiology of dementia - rarer types
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
aetiology of dementia - reversible causes
need to rule out before diagnosing dementia
delirium normal pressure hydrocephalus subdural haemorrhage tumours vit B12 deficiency hypothyroidism hypercalcaemia alcohol misuse neurosyphilis drugs
triad of symptoms in normal pressure hydrocephalus
memory changes, urinary difficulties, gait disturbance
course of dementia
time length varies with each patient
not all patients end up in nursing homes but most require additional care
what is alzheimer’s disease
early impairment of memory and executive function
gradual progression w/ often uncelar onset
what are the main features of AD
amyloid plaques and tau tangles
atrophy following neurone death
reduction in acetylcholine
risk of AD
increases w/ age
1% 50y/o
5% 65y/o
doubles every 5yrs
40% of those 85y/o
SPECT scans
most commonly used scan for AD
blue = less perfusion, less activity
typical presentation of vascular dementia
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
key features of Lewy body dementia
visual halllucinations - e.g. patterns on the walls, small animals
fluctuations
parkinsonism
supportive features in Lewy body dementia
sensitivity to antipsychotics
reduced dopamine uptake DAT scan
increased falls
REM sleep disorder
what is used to diagnose Lewy body dementia
DIAMOND
used for pts and carers also
DAT scan in DLB
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
features of FTD
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
behavioural and psychological symptoms in depression
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
drug treatment of dementia
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
ACh inhibitors
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
side effects of ACh inhibitors
N+V, diarrhoea fatigue, insomnia muscle cramps headaches, dizziness syncope breathing problems
ECG prior to starting
examples of ACh inhibitors
donezapil
galantamine
rivastigmine
risk associated w/ antipsychotic use in dementia
stroke
death
guidance on antipsychotic use
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
non-pharmacological approaches to distress
consider other causes knowing the patient ABC approach communication - w/ pt and family any form of distraction
prevalence of dementia in care homes
3/4 of redsidents have dementia
1/3 of people w/ dementia live in care homes
issues in nursing homes
little continuity of staff
lots of BPSD - exacerbates symptoms
psychosocial interventions recommended but medication often has to be relied on
6Cs of capacity
capacity consent compliance coercion certification common sense
functional illness - what to consider if it isn’t dementia
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
prevalence of depression in the elderly
15% have symptoms in the community
3% have illness
F:M 1.5:1
20-30% in residential care
clinical features of depression in the elderly
less:
depressed mood
expressed suicidal wishes
more: insomnia hypochondriasis suicide agitation
aetiology of depression in the elderly
loss: health wealth spouse work home
genetic
management of depression in the elderly
antidepressants - NB TCAs side effects
CBT
ECT in severe cases
need for prophylaxis
most community cases not treated
prognosis of depression in the elderly
mortality x2
25% chronic
better w/ treatment
normal grief, mourning and bereavement
alarm numbness pining - illusions or hallucinations may occur depression recovery and reorganisation
abnormal grief, mourning and bereavement
persisted >2mths guilt thoughts of death worthlessness psychomotor retardation prolonged and marked functional impairment psychosis
suicide rate in the elderly
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
prevalence of late onset sz like psychosis
up to 10% of psychiatric admissions in old age
clinical features of late onset sz like psychosis
spectrum from circumscribed persecutory delusions to full sz like psychosis
aetiology of late onset sz like psychosis
sensory loss
social isolation
genetic
? minor abnormalities
management of late onset sz like psychosis
often needs compulsory admission
neuroleptics
increased social contact
prognosis of late onset sz like psychosis
may fail to regain insight
high relapse if stop neuroleptics
