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
