Old Age psychiatry Flashcards
ABCD of dementia
A - ADLs
B - behavioural and psychiatric symptoms of dementia
C - cognitive impairment
D - decline
cognitive features of dementia
memory (dysmenesia/amnesia)
+
- dysphagia (communication)
- dyspraxia (inability to carry out motor skills)
- dysgnosia (not recognising objects)
- dysexecutive functioning (initiation, inhibition, set-shifting, abstraction)
What are examples of instrumental ADLs?
keyboard
phone
appointments
buses
What type of functional decline occurs first in dementia?
Instrumental ADLs
Neuropsychiatric disturbance in dementia
Psychosis Depression Anxiety Altered circadian rhythms Agitation
Types of dementia
Alzheimer’s
Vascular (step wise progression)
Lewy body (parkinsons)
Mixed Alzheimer’s and vascular
Course of dementia
Symptoms diagnosis loss of functional independence behavioural problems nursing home placement death
Features of dementia
INSIDIOUS ONSET WITH UNKNOWN DATE slow, gradual, progressive decline generally irreversible disorientation in late illness SLIGHT DAY TO DAY VARIATION LESS PROMINENT PHYSIOLOGICAL CHANGES consciousness clouded only in late stage normal attention span disturbed sleep - wake cycle Psychomotor changes late in illness
Features of delirium
ABRUPT, PRECISE ONSET, KNOWN DATE Acute illness, lasting days or weeks Usually reversible Disorientation early in illness VARIABLE, HOUR BY HOUR PROMINENT PHYSIOLOGICAL CHANGES Fluctuating levels of consciousness short attention span disturbed sleep wake cycle; hour to hour variation n Marked early psychomotor changes
Features of depression
Abrupt onset history of depression HIGHLIGHTS DISABILITIES dont know answers diurnal variation in mood fluctuating cognitive loss tries less hard to perform and gets distressed by losses short and long term memory loss depressed mood coincides with memory loss associated with anxiety
What does a brain scan tell you about dementia?
The aetiology
NOT THE DIAGNOSIS
Criteria for dementia with lewy bodies (DLB)
Dementia Amnesia not prominent - deficits of attention - frontal executive - visuospatial Two of these factors = probable, one = possible - fluctuation (marked, important feature) - visual hallucinations - parkinsonism Suggestive features - REM sleep disorder - severe antipsych severity - abnormal DAT scan supportive by - falls, syncope, loss of consciousness - other psychiatric symptoms - autonomic dysfunction - scans
Diagnosis of LBD is less likely if
stroke disease
other brain / systemic illness
What does a DAT scan look at?
Dopamine receptors
LBD on a DAT scan
reuptake of dopamine transporter in the head of the caudate nucleus and putamen is reduced in the putamen, leading to the “full stop sign” instead of the “comma sign”
Signs of Alzheimer’s on MRI
Brain atrophy
Gyri more obvious
Presentation of frontotemporal dementia (FTD)
Behavioural disorder - personality change Can be early onset Early emotional blunting Speech disorder - altered output - sterotypy - echolalia - preservation - mutism Frontal dysexecutive syndrome Neuroimaging abnormalities in frontotemporal lobes Neurological signs commonly absent early, parkinsonism later, autonomic; incontinence, primitive reflexes Picks disease
Features of frontal dysexecutive syndrome
Memory
Praxis
Visuospatial function not severely impaired
Presentation of subcortical vascular dementia
gradual deterioration in executive function
mood changes such as apathy or irritability
memory often relatively spared
may have additional neurological features
- falls
- incontinence
- seizures
Why is memory often relatively spared in subcortical vascular dementia?
Due to the preservation of cortical grey matter
Drug treatment of dementia
Acetylcholinesterase inhibitors (AChl) for mild to moderate SDAT - donepezil
Memantine for moderate to severe SDAT
Antipsychotics (e.g. risperidone) to manage behavioural problems and psychosis
Antidepressants (e.g. sertraline)
- to enable sleep, and to deal with mood problems and anxiety
Anxiolytics e.g. lorazepam
Hypnotics e.g. zolpidem
Anticonvulsants e.g. valproate for behavioural disturbance but not much used
What is there a risk of in the use of hypnotics to treat dementia?
Falls
What do cholinesterase inhibitors do?
Improve cognitive function Slow decline Improve non cognitive symptoms - ADL - longer at home - reduce carer stress
S/Es of cholinesterase inhibitors
nausea, vomiting diarrhoea fatigue insomnia muscle cramps headaches dizziness syncope breathing problems
What is capacity?
Abilities relevant to competence
- understanding
- manipulating
- approaching the situation and its consequences
- communicating choices
When is guardianship used?
When the patient no longer has the capacity to get a power of attorney
What are the two types of power of attorney?
Finance
Welfare
In old age psychiatry, who is most associated with suicide?
Elderly males - associations with alcohol and widowed etc
Normal symptoms of grief, mourning and bereavement
alarm numbness pining - illusions or hallucinations may occur depression recovery and reorganisation
Abnormal symptoms of grief, mourning and bereavement
Persisted beyond 2 months guilt thoughts of death worthlessness psychomotor retardation prolonged or marked functional impairment psychosis
Suicide rate for the elderly has the same rate as what age group?
< 25 y/o
Presentation of late onset schizophrenia like psychosis
Spectrum from circumscribed persecutory delusions to full schizophrenia like psychosis
Causes of late onset schizophrenia like psychosis
Sensory loss
social isolation
genetic - possible minor abnormalities
Treatment of late onset schizophrenia like psychosis
often needs compulsory admission
neuroepileptics
social contact
Prognosis of late onset schizophrenia like psychosis
May fail to regain insight
high relapse rate if stop neuroepileptics
Who should not drive in dementia?
Those with poor short term memory, disorientation or lack of insight
Simple definition for dementia
Cognitive and functional decline > 6 months
Definition of dyspnogia
Poor recognition
Definition of dyspraxia
Motor skills
What makes up executive function?
Initiation of tasks Inhibition (knowing when to stop) Set shifting Abstraction Problem solving
What is set shifting?
Multi-tasking
What do you look at to see if the person is functioning?
ADLs
What is “reversible” dementia?
Not actually dementia, another condition causing the symptoms
Causes of reversible dementia
Normal pressure hydrocephalus Subdural haematoma Tumours Neurosyphillis / HIV Vitamin deficiencies - B12, folate Hypothyroidism
Types of dementia
Alzheimers Vascular Mixed AD + VD Lewy Body Frontotemporal Alcohol Subcortical Prion protein
Pathology of alzheimers dementia
Atrophy of key brain regions
Type of progression of alzheimers
Progressive
Type of progression of VD
Step wise (up and down)
Features of lewy body dementia
Dementia
Parkinsonism
Hallucinations
Fluctuation
What type of hallucinations tend to be seen in lewy body dementia?
Visual
Features of FTD
Behavioura
DNFA
Progressive non fluent aphasia
Semantic
Examples of subcortical dementia
Parkinsons
Huntingtons
HIV
What indicates LBD? (motor and cognitive decline)
Onset of motor and cognitive decline within 1 year
What indicates parkinsons dementia (motor and cogntivie decline)?
Onset of cognitive decline 1 year after motor symptoms
Differential diagnosis for confusion
Normal Dementia Depression Delerium / acute confusional state Mild cognitive impairement (mild memory impairment)
What does BPSD stand for?
Behavioural and psychological symptoms in dementia
Presentation of BPSD
Agitation Psychosis Affective Disinhibition Behaviour
How can depression be differentiated from dementia?
Depression - short history and rapid onset
