Old Age Psychiatry Flashcards
What are MHOA Teams?
- MHOA = Mental health of older adults
- Serve people aged 65 and over
- Experts in dementia care
- Team consists of social workers, nurses, psychologists, occupational therapists, and psychiatrists
- focus less on symptoms themselves and more on how these symptoms affect everyday life and functioning;
- they often assess people at home, to under-stand how they’re coping in a familiar environment.
- Working closely with carers, teams enhance quality of life and support people to stay in their own homes as long as possible
How common is depression in the elderly?
About 15% of older people, and 30% of older hospital inpatients, are depressed at any time
What is depression in later life associated with? What are the risk factors?
- Depression inlater life (particularly a first episode) may be associated with cerebrovascular disease, vascular risk factors, and current or future cognitive deficits.
- Other risk factors more commonly affecting older people include:
- bereavement
- isolation
- poverty
- chronic pain
- physical illness
- polypharmacy (multiple medications, making drug side effects and interactions more likely).
How does depression present in older people?
Presents similarly but may show more:
- Physical symptoms, e.g. constipation, insomnia,fatigue.
- Psychomotor agitation/ retardation.
- Memory problems.
- Executive dysfunction.
Pseudodementia is when memory problems are so bad that depression resembles dementia.
Self- neglect and poor oral intake are important risks in older people and may be the first signs of depression.
Suicide rates are higher (especially in men), so suicidal thoughts should be taken very seriously.
How should we manage depression in the elderly?
Similar to that of younger people:
- Problem-solving, increasing socialisation and day-time activities
- Psychological therapies (e.g. CBT, psychodynamic therapy, group therapy, family therapy, couple therapy)
- Antidepressants: SSRIs are first line (e.g. citalopram) though they may cause hyponatraemia → monitor sodium levels
- Mirtazapine can improve sleep and appetite, so may be preferred in frail, older people with insomnia
- ECT is sometimes used in psychotic or life-threatening depression
- Consider social workers, community nurses and carers
- Recommend Age UK
How common are anxiety disorders in the elderly? Who is it more common in?
The prevalence and incidence of anxiety disorders fall with age, possibly because of under-reporting.
They’re more common in women and in isolated people or those who’ve had adverse experiences.
What is the management of anxiety disorders in the elderly?
Management is usually through CBT, although SSRIs can help
What is late onset and very late onset psychosis?
Functional psychosis can develop for the first time in older people: it’s called ‘late- onset psychosis’ after the age of 40, and ‘very late- onset psychosis’ after 60 (also known as paraphrenia/ late- onset schizophrenia)
Who is at risk of getting psychosis?
- Women are more commonly affected, possibly due to loss of the protective effect of oestrogen after menopause.
- Risk factors include:
- social isolation
- sensory impairment
- cerebrovascular pathology
- being single/widowed
- (for women) without children.
What is the presentation of psychosis in the elderly?
Positive symptoms (delusions and hallucinations) are often more prominent than negative symptoms
What is the management of psychosis in the elderly?
Reduction of sensory impairment (hearing + vision)
- Exclusion of organic cause or LBD
- Low-dose antipsychotics
- CBT
Define dementia.
Dementia is NOT a normal part of ageing. It is an acquired, chronic and progressive global cognitive impairment, sufficient to impair ADLs (activities of daily living).
Problems present in clear consciousness for at least 6 months distinguish dementia from delirium.
What are ADLs?
What is the epidemiology of dementia?
Risk of dementia increases with age and the prevalence is:
- 5% over 65 years
- 20% over 80 years
- Alzheimer’s disease = most common type (60% of cases), followed by vascular dementia and then lewy body
What are the risk factors of Alzheimer’s Disease (AD)?
- Age = major risk factor
- F > M
Vascular risk factors
- Low IQ/poor educational level
- Hx of depression or Head injury
- Genetics (Heretability is about 70%)
- Late- onset or sporadic AD (65+ years) makes up 95% of cases.
- Multiple genes may be involved, but attention has focused on the apolipoprotein E (APOE) ɛ4 allele on chromosome 19.
- The APOE protein seems to be involved in breaking down β- amyloid; the ɛ4 allele is less effective, so having one or two alleles increases the risk of AD.
- Multiple genes may be involved, but attention has focused on the apolipoprotein E (APOE) ɛ4 allele on chromosome 19.
- Familial or early- onset AD (<65 years) is usually due to rare, autosomal dominant mutations affecting presenilin 1 (chromosome 14), presenilin 2 (chromosome 1),or amyloid precursor protein (APP; chromosome 21) genes. These influence the formation or breakdown of APP, predisposing to β- amyloid deposition
What causes Vascular dementia? What are the RFs?
Due to small infarcts caused by thromboemboli or arteriosclerosis (stroke-related dementia)
Risk factors = CV risk factors
- Older age
- Male sex
- Smoking
- HTN
- DM
- Hypercholesterolaemia
- AF
- Hx of TIA/MI
VD may also be caused by amyloid angiopathy, so can occur with AD.
Multiple genes of small effect probably influence susceptibility to VD.
- Rare familial forms of VD can occur, e.g. cerebral autosomal dominant arteriopathy with sub-cortical infarcts and leucoencephalopathy (CADASIL)
CT head showing VD: this non- contrasts can shows areas of lower density adjacent to the anterior and posterior horns of the latera ventricles, due to chronic ischaemia.
What is an AMTS?
How do we treat BPSD?
