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MRCPsych Part B > Old Age Psychiatry 1.2 > Flashcards

Old Age Psychiatry 1.2 Flashcards

1
Q

What happens in Parkinsons?

A

Degeneration of subcortical structures: substantia nigra, caudate, putamen and globus pallidus

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2
Q

What type of disease is Parkinsons?

A

Subcortical degenerative diseases

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3
Q

What do Subcortical diseases effect?

A

Movement
Mood
Cognition

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4
Q

Which patients with Parkinsons are more likely to ave cognitive sx?

A

Those with late onset (>70)

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5
Q

How many patients with Parkinsons go on to develop dementia?

A

10%

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6
Q

What type of deficits are less severe in patients with LBD and Parkinsons vs Alzheimers?

A

Visual and verbal memory deficits

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7
Q

What type of deficits are more severe in LBD and Parkinsons vs Alzheimers?

A

Executive dysfunction:
planning, reasoning, sequencing

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8
Q

What neuropsychological impairments are noted in Parkinsons even if there is no cognitive impairment?

A

Visuospatial tasks

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9
Q

Impact of Parkinsons dementia?

A

Impairs QoL
Exacerbates carers distress
Increases likelihood if residential care
Doubles mortality

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10
Q

Most common SE of Levodopa or dopamine agonists

A

Visual hallucinations with insight

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11
Q

Treatment of psychosis secondary to medications

A

Reduce dose of levodopa or dopamine agonist
Clozapine/Quetiapine

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12
Q

Risk factors for developing psychosis in Parkinsons

A

Older age
Longer duration of illness
Dementia
Severity of illness
Sleep deprivation
Use of dopamine agonists
Polypharmacy

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13
Q

Criteria for diagnosis of LBD

A

If both motor sx and cognitive sx develop within 12 months

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14
Q

Criteria for diagnosis of Parkinsons dementia

A

If parkinsonian sx have existed for >12 months before dementia develops

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15
Q

How does SPECT differentiate between Parkinsons and LBD?

A

LBD shows greater caudate involvement

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16
Q

What is similar in SPECT of both Parkinsons and LBD?

A

Reduced perfusion of precuneus and parietal cortex - associated with visual processing

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17
Q

What does DAT scan detect?

A

Changes in dopamine transporter responsible for allowing brain cells to take up dopamine

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18
Q

What drug is licensed for treatment of Parkinsons Dementia?

A

Rivastigmine

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19
Q

What disorders come under FTD?

A

Picks
Primary progressive aphasia
Semantic dementia
Corticobasal degeneration

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20
Q

Age of onset of FTD

A

40-75

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21
Q

FTD accounts for how many cases of presenile dementia?

A

20%

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22
Q

Which chromosome is linked to FTD?

A

17

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23
Q

Early clinical features of FTD?

A

Personality
Behaviour

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24
Q

Which personality sx are seen in early FTD?

A

Disinhibition
Social misconduct
Lack of insight

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25
Q

Which behavioural sx are seen in early FTD?

A

Apathy
Mutism
Repetitive behaviours

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26
Q

What sx progress as FTD worsens?

A

Frontal and temporal dysfunction

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27
Q

Give e.g. of sx as FTD worsens

A

Behavioural rigidity
Impulsivity
Emotional lability
Fatuosness
Executive dysfunction
Hyperorality

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28
Q

Memory impairment in FTD?

A

Memory is affected later and less severly

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29
Q

What cognition is well preserved in FTD?

A

Spatial orientation

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30
Q

What is characteristically lost early in FTD?

A

Insight

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31
Q

Pathological findings of FTD

A

Asymmetrical focal atrophy of frontotemporal regions
Underlying neuronal loss, gliosis and spongiform changes in affected cortices

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32
Q

What is FTD associated with?

A

MND

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33
Q

Treatment of FTD

A

SSRIs have limited benefit for behavioural sx

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34
Q

What do CT and MRI show in FTD?

A

Bilateral asymmetrical abnormalities of frontal and temporal lobes

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35
Q

What does SPECT show in FTD?

A

Disproportionate decrease in blood flow, radio tracer uptake and glucose metabolism in frontal lobe

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36
Q

What do neuropsychological tests show in FTD?

A

Impaired frontal lobe dysfunction: abstract thinking, attentional shifting, set formation

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37
Q

What functions are spared in FTS in neuropsychological testing?

A

Memory
Speech
Perceptuospatial functions

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38
Q

Onset of Picks disease

A

Slow
Steady deterioration

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39
Q

What sx show predominance of frontal lobe involvement in Picks?

A

Emotional blunting
Coarsening of social behaviour
Disinhibition
Apathy/restlessness
Non-fluent aphasia

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40
Q

What is preserved in early stage Picks disease?

A

Memory
Parietal lobe function

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41
Q

Onset of Picks

A

45-65 years

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42
Q

Gender ratio of Picks

A

Men more affected than women

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43
Q

Average duration of Picks

A

8 years

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44
Q

How many patients with Picks have a FHx?

A

50%

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45
Q

What causes Picks?

A

AD
Mutation in Tau gene with complete penetration

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46
Q

Where is the tau gene?

A

Chromosome 17q 21-22

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47
Q

What is pathognomic of Picks disease?

A

Picks cells

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48
Q

How do Picks cells appear?

A

Swollen and stain pain on H and E stains

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49
Q

What is absent in the pathology of Picks?

A

Senile plaques
Neurofibrillary tanges

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50
Q

What other pathology can be found in Picks?

A

Demyelination and fibrous gliosis of frontal lobe white matter

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51
Q

CT and MRI signs of Picks?

A

Mild generalised atrophy but marked atrophy of frontal and temporal lobs with sparing of posterior third of superior temporal gyrus - knife blade atrophy

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52
Q

What happens in primary progressive aphasia?

A

Progressive decline in language with sparing of other cognitive deficits.

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53
Q

Speech in primary progressive aphasia?

A

Non-fluent and effortful
Poor output
Mute in later stages

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54
Q

MRI scan in primary progressive aphasia?

A

Predominant atrophy of perisylvian region

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55
Q

Speech in semantic dementia

A

Fluent
Impaired understanding of word meaning
Naming difficulties
Use of substitute words

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56
Q

MRI findings in semantic dementia

A

Disproportionate asymmetric atrophy of temporal lobe (more left)
Atrophy of anterior temporal lobe more pronounced than posterior temporal lobe

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57
Q

What type of dementia do most patients <65 years of age have?

A

Alzheimers

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58
Q

Which conditions are rarely seen in senile patients?

A

Progressive supranuclear Palsy
Corticobasal degeneration
Frontotemporal degeneration

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59
Q

In which types of early dementia are genetic abnormalities important?

A

Frontotemporal dementia with Parkinsonism - chromosome 17
Familial Alzheimers

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60
Q

Characteristics of early onset dementia?

A

Rapid progression of cognitive impairment with neuropsychological syndromes and neurological sx

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61
Q

What sx are common in early onset dementia?

A

Language problems
Visuospatial dysfunction

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62
Q

Which genes have been identified in familial Alzheimers with early onset?

A

Amyoid precursor gene - APP
Genes encoding PSEN1 and 2

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63
Q

Onset of Progressive Supranuclear Palsy

A

45-75 years

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64
Q

Presentation of PSP

A

Balance difficulties
Abrupt falls
Slurred speech
Dysphagia
Vague changes in personality
Agitated depression

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65
Q

Most common early complaint in PSP?

A

Unsteadiness of gait and unexplained falling

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66
Q

Characteristic sx of PSP

A

Supranuclear opthalmoplegia
Pseudobulbar palsy
Axial dystonia
Vertical gaze palsy

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67
Q

What is vertical gaze palsy?

A

Difficulty in voluntary vertical movement of eyes

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68
Q

What is Bells phenomenon?

A

Reflexive upturning of eyes on forced closure of eyelids

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69
Q

Which eye movements are lost in PSP?

A

Vertical eye movements
Bells Phenomenon
Ability to converge
Dilatation of pupils

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70
Q

Characteristic eye expression of PSP

A

Upper eyelids retract
Wide-eyed, unblinking state imparting expression of perpetual surprise

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71
Q

What type of dementia occurs in PSP?

A

Subcortical

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72
Q

Sx of delirium

A

Rapid onset with fluctuations
Clouding of consciousness
Reduced attention span
Disturbance of sleep/wake cycle

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73
Q

Cognitive sx of delirium

A

Global impairment of cognition with disorientation and impairment of recent memory and abstract thinking

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74
Q

Sleep/wake cycle in delirium

A

Nocturnal worsening of sx

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75
Q

Speech in delirium

A

Rambling, incoherent and thought disordered

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76
Q

What characterises hyperactive delirium?

A

Increased motor activity
Agitation
Hallucinations
Inappropriate behaviour

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77
Q

What characterises hypoactive delirium?

A

Reduced motor activity
Lethargy

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78
Q

Which type of delirium has a poorer prognosis?

A

Hypoactive

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79
Q

Prevalence of delirium on admission to hospital

A

10-15% of elderly

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80
Q

Prevalence of delirium in the elderly during hospital

A

10-40%

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81
Q

Point prevalence of delirium in the general population

A

0.4%

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82
Q

Point prevalence of delirium in general hospital admissions

A

9-30%

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83
Q

Prevalence of delirium post-op

A

5-75%

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84
Q

Prevalence of delirium in ITU

A

12-50%

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85
Q

Prevalence of delirium in nursing homes

A

60%

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86
Q

Duration of delirium

A

Sudden onset
Lasts less than 1 week
Resolves quickly

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87
Q

Major pathway implicated in delirium?

A

Dosral tegmental pathway which projects from mesenchephalic reticular formation to tectum and thalamus

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88
Q

What is reticular formation of brainstem impottant for?

A

Regulating attention and arousal

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89
Q

Which neurotransmitter is involved in delirium?

A

Acetylcholine

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90
Q

EEG in delirium?

A

Generalised slowing of activity

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91
Q

What type of memory is impaired in delirium?

A

Recent and immediate

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92
Q

Sleep/wake cycle in delirium

A

Frequent disruption
Day/night reversal

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93
Q

Name the rating scales for delirium

A

Delirium rating scale - DRS
MMSE
CTD - cognitive test for delirium
CAM - confusion assessment method

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94
Q

Most widely used scale for delirium?

A

DRS

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95
Q

Advantage of DRS?

A

Distinguishes delirium from dementia

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96
Q

What is required for DRS use?

A

Interpretation by skilled clinician
Information from multiple clinical sources

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97
Q

What does MMSE emphasise?

A

Neuropsychological functions linked to left cerebral hemispheric activity

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98
Q

Problem of MMSE in use of delirium

A

Many of core features of delirium reflect non-dominant hemispheric functions

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99
Q

What does CTD allow?

A

Detailed investigation of range of neuropsychological functions

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100
Q

What patients is CTD useful for?

A

Patients whose ability to interact may by compromised

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101
Q

Which delirium rating scale has high sensitivity and specificity?

A

CAM

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102
Q

What does CAM allow?

A

Diagnosis of delirium
Incorporated into routine clinical settings

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103
Q

What can reduce sensitivity of CAM?

A

If used by nursing staff rather than physicians

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104
Q

Environmental support measures for delirium

A

Education
Reorientation
Reassurance
Adequate lighting
Reduce unnecessary noice
Consistent staffing

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105
Q

Management of delirium

A

Environment
Regular clinical review and follow-up
Optimise hydration, nutrition, pain, sensory impairments

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106
Q

What test is useful for review of delirium and cognitive improvement

A

MMSE

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107
Q

Effective medication for delirium

A

Low dose haloperidol

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108
Q

NICE guidelines for medical management of delirium

A

<1 week use of Haloperidol or Olanzapine

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109
Q

When can benzos be useful in delirium?

A

If caused by withdrawal of alcohol or sedatives

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110
Q

Risks of benzo use in delirium?

A

Increases agitation
In elderly increases risk of falls and disinhibition

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111
Q

Prevalence of depression in >65 age group

A

10-15%

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112
Q

How much more common is depression in nursing homes?

A

2-3 times more common

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113
Q

Which medical conditions are associated with high risk of depression?

A

Cardiovascular disease
CNS disorders - stroke, dementia, Parkinsons
Cancer

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114
Q

How many people with dementia have depression?

A

25%

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115
Q

Ethnic variations in elderly with depression?

A

Elderly african americans have less rates of depression than elderly caucasians

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116
Q

Clinical features of depression in the elderly compared to young

A

Low mood may be less prevalent
More hypochondrical, somatic and delusional sx

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117
Q

Sx of depression in the elderly

A

Hypochondriasis and somatic concerns
Poor subjective memory
Late onset neurotic sx
Apathy and poor motivation

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118
Q

Cognitive impairment rates in those with depression in the elderly

A

70%

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119
Q

How many elderly patients with depression show psychomotor changes?

A

30%

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120
Q

What sx are more common in elderly depression?

A

Cognitive impairment
Psychomotor changes
Depressive delusions
Paranoia and auditory hallucinations
Weight loss
Severe life stress

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121
Q

Risk factors for late-onset depression

A

Female
Poor health
Disability
Poor perceived social supported

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122
Q

Neuroimaging findings in late onset depression

A

Ischaemic changes
Reduction in gray matter volume in frontal and temporal lobes
Sulcal widening
Reduction in volume of caudate nucleus
Reduction in volume of hippocampus

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123
Q

CT findings in late onset depression

A

Cortical atrophy
Ventricular enlargement

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124
Q

MRI findings in late onset depression

A

Atrophy
Ventricular enlargement
Lesions in basal ganglia and white matter

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125
Q

SPECT findings in late onset depression

A

Reduced cerebral blood flow, sparing the posterior parietal cortex

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126
Q

NNT for antidepressant use in elderly

A

4 - similar to other age groups

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127
Q

Dosage of antidepressants in elderly with depression

A

Start at lower dose, but treatment dose should be same as for adults

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128
Q

First line treatment of late onset depression

A

SSRI

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129
Q

Recovery of late onset depression

A

Elderly take longer to recover - may take 6-8 weeks to respond to antidepressants

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130
Q

How many elderly patients do not respond to antidepressant medication for depression?

A

30%

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131
Q

Recovery rate of severe depression with ECT?

A

80%

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132
Q

SE of ECT in the elderly?

A

More likely to suffer from post ECT confusion and cognitive impairment
Memory impairment worse with bilateral electrode placement

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133
Q

Evidence of psychological therapy for depression in the elderly

A

Just as effective as medication for mild-moderate depression

134
Q

What is best treatment for relapse prevention of depression in the elderly?

A

Combination of medication and therapy

135
Q

Best therapies for depression in the elderly?

A

CBT
Interpersonal therapy
Problem solving treatment
Family therapy

136
Q

Relapse rates in elderly with depression compared to adults?

A

Higher relapse rates in the elderly

137
Q

Mortality of elderly with depression?

A

Higher due to physical disorders

138
Q

Good prognostic factors for late onset depression

A

Onset <70 years of age
Short duration of illness
Absent physical illness
Good previous recovery
Good previous adjustment

139
Q

Poor prognostic factors for late onset depression

A

Severe life events during follow-up
Poor medication adherence
Severity of initial illness
Comorbid physical illness
Presence of psychotic sx
Duration of illness >2 years
3 or more previous episodes
Previous hx of dysthymia
CVD

140
Q

Depression and MI in the elderly

A

Elderly individuals with depression were 4x more likely to die within 4 months of MI

141
Q

Link between MI and depression in the elderly?

A

Platelet aggregation raised in patients with depression

142
Q

Link between fractures and depression in the elderly?

A

Elderly with depression have poor T cell responses to mitogens and high conc of plasma interleukin 6 which is indicative of inflammatory activity that might increase risk of bone resorption, predisposing to factors

143
Q

Depression scales for the elderly

A

Geriatric depression scale
BASDEC
Hamilton
MADRS
Depressive sign scale
CSDD
PHQ 9

144
Q

How many items in Geriatric depression scale?

A

15

145
Q

How long does geriatric depression scale take to complete?

A

4-5 minutes

146
Q

Scoring in geriatric depression scale?

A

> 5 suggests depressive illness

147
Q

Advantage of geriatric depression scale?

A

Avoids somatic sx

148
Q

What does BASDEC stand for?

A

Brief assessment schedule depression cards

149
Q

What is BASDEC?

A

Series of statements in large print on cards which are shown to patients; answer T/F

150
Q

Why is Hamilton not as appropriate for the elderly?

A

Somatic items

151
Q

What does MADRS stand for?

A

Montgomery-Asberg depression rating scale

152
Q

Advantages of MADRS

A

Sensitive to change in depression

153
Q

Disadvantages of MADRS

A

Not reliably answered by patients with dementia

154
Q

What does Depressive sign scale consist of?

A

9 items

155
Q

Advantage of depressive sign scale?

A

Helps detect depression in people with dementia

156
Q

What does CSDD stand for?

A

Cornell scale for depression in dementia

157
Q

What is the best validated scale for detecting depression in dementia patients?

A

CSDD

158
Q

How does CSDD work?

A

Interviewer-administered
Using info from both patient and an informant

159
Q

Factors involved in CSDD

A

General depression
Biologic rhythm disturbances
Agitation/psychosis
Negative sx

160
Q

How many items in PHQ 9?

A

9
Self-report

161
Q

Advantages of PHQ 9

A

Easy to use
Sensitive to change

162
Q

Cognitive impairment in late onset depression

A

Specific deficits in attention and executive function, consistent with frontal lobe dysfunction

163
Q

Cognitive deficits in early onset depression

A

Deficits in episodic memory - consistent with temporal lobe dysfunction

164
Q

What is pseudodementia?

A

When patients develop dementia during episodes of depression that subsides after remission of depression

165
Q

How many patients with pseudodementia develop true dementia within 3 years?

A

40%

166
Q

Sx duration of pseudodemtnia vs dementia

A

Pseudodementia: short duration

Dementia; long duration

167
Q

Sx progression in pseudodementia vs dementia

A

Pseudodementia: rapid progression

Dementia: slow progression

168
Q

Attention and concentration in pseudodementia vs dementia

A

Pseudodementia: preserved attention and concentration

Dementia: not well preserved

169
Q

Memory loss in pseudodementia vs dementia

A

Pseudodementia: memory loss for recent and remote events, severe

Dementia: memory loss for recent events more severe than for remote events

170
Q

Who suggested that vascular depression was a subtype of geriatric depression?

A

Alexopoulous

171
Q

Pathology underlying vascular depression

A

Cerebral ischaemic damage to frontal subcortical circuits could lead to late onset depression

172
Q

Clinical features of vascular depression

A

Apathy
Psychomotor retardation
Poor executive function
Less depressive thinking
Late age of onset

173
Q

Features of vascular depression which are not as common in late onset depressino

A

Apathy
Retardation
Lack of insight
Less agitation and guilt

174
Q

Most impaired cognitive functions in vascular depression?

A

Verbal fluency
Object naming

175
Q

Theories explaining association depression and vascular disease

A

Increased platelet aggregation
Recurrent depression may increase risk of vascular pathology
Damage to end arteries supplying subcortical stirato-pallido-thalamo-corticol pathways may disrupt neurotransmitter circuitry involved in mood regulation

176
Q

What is more common in MRI of depressed elderly than non-depressed elderly?

A

White matter lesions

177
Q

What do white matter lesions on MRI in depressed elderly patients correlate with?

A

Poorer response to treatment of depression

178
Q

Who studied the associatino between subcortical lesions and antidepressant response in late onset depression?

A

Simpson et al

179
Q

What did Simpson et al’s study show?

A

Poor response to antidepressants in patients with vascular depression
Drugs used for prevention of CVD might reduce risk of vascular depression

180
Q

Which antidepressants promote ischaemic recovery?

A

Dopamine or norepinephrine enhancing agents

181
Q

Which antidepressants inhibit ischaemic recovery?

A

Adrenergic blocking agents

182
Q

What % of mood disorders in the elderly are due to mania?

A

5-10%

183
Q

One year prevalence of bipolar among adults >65?

A

0.4%

184
Q

Difference in mania in the elderly?

A

More often followed by a depressive episode
Mixed affective presentations are more common

185
Q

What are patients with first episode mania in late life at risk of?

A

Twice as likely to have comorbid neurological disorder.

186
Q

Cognitive function in late onset mania

A

Cognitive function is significantly impaired between a fifth and third of elderly patients

187
Q

Imaging study findings in elderly with late life mania

A

High rate of cerebral white matter lesions

188
Q

What is secondary mania?

A

Manic illness that starts without prior hx of affective disorder in close temporal relationship to physical illness or drug treatment and often in absence of family illness of affective illness.

189
Q

Which conditions are associated with secondary mania?

A

Stroke - mainly right-sided lesions
HI
Tumours
Endocrine infections
HIV
Medications

190
Q

Which drugs can cause mania?

A

Steroids
Anti-Parkinson drugs

191
Q

Treatment of mania in the elderly

A

Lithium but at lower doses
Valproate
Antipsychotics in severe illness

192
Q

Therapeutic range for prophylaxis of mania in the elderly?

A

0.4-0.6

193
Q

When are psychotic sx commonly seen in the elderly?

A

Delirium due to medical condition
Drug misuse
Drug-induced psychosis

194
Q

What neurodegenerative conditinos can cause psychosis?

A

Alzheimers
Vascular Dementia
LBD
Parkinsons

195
Q

Who coined the term paraphrenia?

A

Kraepelin in 1913

196
Q

What is paraphrenia?

A

Late life psychosis

197
Q

What are the two points of view of paraphrenia?

A
  1. It is nothing more than the expression of schizophrenia in the elderly
  2. It is different from schizophrenia and associated with a different set of pathogenic factors in the elderly
198
Q

What is late onset psychosis divided into?

A

Late onset >40 years
Very late onset >60 years

199
Q

What % of the elderly population in psychiatric hospital have late onset psychosis?

A

10%

200
Q

Prevalence of late onset psychosis in the community

A

0.1-4%

201
Q

Incidence of late onset psychosis

A

10-26 per 100,000 per year

202
Q

Point prevalence of paranoid ideation in the elderly population?

A

4-6%

203
Q

Gender differences in late onset psychosis

A

More females affected

204
Q

Most common feature of late onset psychosis

A

Persecutory delusions

205
Q

How many patients with late onset psychosis have persecutory delusions?

A

90%

206
Q

How many patients with late onset psychosis have auditory hallucinations?

A

75%

207
Q

How many patients with late onset psychosis have visual hallucinations?

A

60%

208
Q

What sx are less common in late onset psychosis?

A

First rank
Negative sx
Thought disorders

209
Q

How many patients with late onset psychosis present with delusions only?

A

10-20%

210
Q

What type of delusions are common in late onset psychosis?

A

Persecutory
Partition delusions

211
Q

What are partition delusions?

A

Attack through the wall or ceiling is passed through by a person, radiation/gas or neighbours spying via a partition

212
Q

ICD diagnosis of paraphrenia?

A

No such diagnosis
Patients must be diagnosed either with schizophrenia or delusional disorder

213
Q

What characterises late onset psychosis?

A

Fewer negative sx
Better response to antipsychotics
Better neuropsychological performance
Greater likelihood of visual hallucinatinos
Lesser likelihood of formal thought disorder or affective blunting
Greater risk of Tardive Dyskinesia

214
Q

Risk of tardive dyskinesia in the elderly on antipsychotics?

A

Increased 5-6 times

215
Q

Relatives of very late onset psychosis vs relatives of early onset?

A

Relatives of very late onset have lower morbid risk for schizophrenia

216
Q

Prevalence of schizophrenia in siblings

A

7%

217
Q

Prevalence of schizophrenia in parents

A

3%

218
Q

What is less impaired in late onset psychosis?

A

Premorbid educational, occupational and psychosocial functioning

219
Q

What personality traits are noted in people with late onset psychosis?

A

Premorbid schizoid or paranoid personality traitrs

220
Q

Risk factors for late onset psychosis

A

Age related changes in frontal and temporal cortices
Cognitive decline
Social isolation
Sensory deprivation - hearing/visual loss
Polypharmacy
Paranoid/schizoid traits
Precipitating life events
Female
FHx

221
Q

What must be excluded before antipsychotics can be used in late onset psychosis?

A

LBD

222
Q

Which antipsychotics are considered more suitable for the elderly?

A

Atypical

223
Q

Advice re starting antipsychotics in the elderly

A

Start low
Go slow

224
Q

What does research suggest re use of conventional antipsychotics in the elderly?

A

Significant improvement with haloperidol and trifluoperazine

225
Q

Risks of clozapine use in the elderly

A

Toxicity
More frequent occurrence of agranulocytosis

226
Q

What factors may contribute to neurotic sx in the elderly?

A

Physical frailty
Major life events
Bereavement
Social isolation
Poor self-care
Insecure personality

227
Q

Prevalence of neurotic disorders in the elderly?

A

1-10%

228
Q

Most prevalent psychiatric disorder in >65

A

Anxiety

229
Q

Correlation between anxiety and age?

A

Prevalence of anxiety disorders decreases with age

230
Q

Most prevalent anxiety disorder in the elderly?

A

Phobic disorders

231
Q

Least common anxiety disorder in the elderly?

A

Panic disorder

232
Q

What anxiety sx dominate in the elderly?

A

Hypochondriacal and depressive sx

233
Q

What sx are less common in the elderly with anxiety?

A

Obsessional, phobic, dissociative and conversion disorders

234
Q

What is a common response to anxiety in the elderly?

A

Sedative drugs
Alcohol

235
Q

What are most cases of agoraphobia in the elderly a result of?

A

Alarming experience of physical ill health

236
Q

What do patients need to be warned about when starting medication for anxiety

A

Transient increase in anxiety in first 1-2 weeks

237
Q

What medications should be used for GAD?

A

Fluoxetine
Paroxetine
Venlafaxine

238
Q

What medications should be used for panic disorder?

A

Citalopram

239
Q

What medications should be used for PTSD?

A

Fluoxetine
Paroxetine

240
Q

Why are the elderly likely to encounter alcohol disorders at lower intake levels than the general population?

A

Effects of physical and cognitive ageing
Pharmacokinetic changes
Increased prevalence of co-morbid illness
Interactions with medications

241
Q

Alcohol misuse in males vs females

A

Men are twice as likely to exceed safe drinking limits

Women report more late onset alcohol problems

242
Q

Which men are at increased risk of heavy drinking?

A

Widowed or divorced

243
Q

Which older women are at increased risk of alcohol misuse?

A

Married

244
Q

Features of early onset alcohol misuse

A

Lifelong pattern of problem drinking
FHx of alcoholism

245
Q

Age of onset of alcohol misuse in early onset?

A

20-30

246
Q

Age of onset of alcohol misuse in late osnet

A

40-50 years

247
Q

Features of late onset alcohol misuse

A

Fewer physical and MH problems
Stressful life event as precipitator
More receptive to treatment

248
Q

Medications used to reduce relapse in alcohol misuse

A

Disulfiram
Acamprosate
Naltrexone

249
Q

Why do some studies suggest disulfiram should not be used in the elderly?

A

Increased risk of serious adverse effects such as acute confusion.

250
Q

Contraindications of disulfiram?

A

Hx of HTN, CCF, CVE or IHD

251
Q

Lifetime prevalence of drug misuse in the elderly

A

1.6%

252
Q

Most commonly prescribed psychotropic drug in the elderly?

A

Benzos

253
Q

Risk of suicide and age

A

Incidence of DSH goes down with risk
Completed suicide rises with age
Suicidal intent behind acts of DSH greater in the elderly

254
Q

Most common method of DSH in the elderly

A

OD

255
Q

Most common drugs used in OD in the elderly

A

Benzos
Analgesics
Antidepressants

256
Q

Psychiatric disorders in elderly who DSH

A

Depression - half
Alcohol abuse - one third

257
Q

Risk factors for DSH in the elderly

A

Physical illness
Widowhood/divorced/separation
Social isolation
Living alone
Unresolved grief

258
Q

How many elderly patients who died from suicide had depression?

A

70%

259
Q

What sx of depression are associated with suicide in the elderly?

A

Chronic sx of depression
First depressive illness in later life
Inadequately treated depression
Co-morbid physical illness

260
Q

Social risk factors for suicide in the elderly?

A

Social isolation
Lack of support
Concerns over dependents
Move from home to residential care
Grief reaction greater than one year

261
Q

What did the Monroe County sample find re the elderly and suicide (>50 years)?

A

Suicide was associated with higher levels or Neuroticism and lower scores on openness to experience

262
Q

What did Harwood and colleagues found in patients >60 who committed suicide?

A

Anankastic and anxious traits were associated with both depression and suicidality in the elderly

263
Q

Prevalence of PDs in the elderly

A

5-10%

264
Q

Which personality traits increase wit age?

A

Cautiousness
Obsessionality
Compulsive Traits
Introversion

265
Q

Which traits ‘burn out’ with age?

A

Psychopathy
Criminal behaviour

266
Q

Which PD has reduced prevalence in the elderly?

A

Antisocial
Histrionic

267
Q

Which PD has the highest prevalence in the elderly?

A

OCD

268
Q

Prevalence of OCD PD in the elderly?

A

3.3%

269
Q

Links between elderly with PD and other MI?

A

Patients with PD are 4x more likely to have depression or GAD

270
Q

Which personality traits are likely to occur in patients with depression irrespective of age?

A

Avoidant
Dependant
Compulsive

271
Q

How many patients with dementia report negative personality change?

A

2/3

272
Q

What patterns of personality change are reported in patients with organic disorders?

A

Alteration at onset of dementia with little subsequent change
Ongoing change with disease progression
Regression to previously disturbed behaviours
No change

273
Q

What is Diogenes syndrome?

A

Self-neglect in older people in which eccentric and reclusive individuals become increasingly isolated and neglect themselves.

274
Q

Characteristics of patients with Diogenes syndrome?

A

Oblivious to their condition
Resistant to help
Hoarding (syllogomania)

275
Q

Sleep changes in the elderly?

A

Reduced total sleep time
Increased daytime napping
Increased nighttime arousals and recalled awakenings
Longer sleep latency
Increased stage 1 & 2 sleep
Reduced SWS and REM sleep
Shorter REM latency

276
Q

What is insomnia in the elderly associated with?

A

Depression
Heart disease
Pain
Memory problems

277
Q

Which sleep disorders are common in the eldrely?

A

Insomnia
Circadian rhythm disorders
RLS
REM sleep behaviour disorder
OSA

278
Q

What medications reduce REM sleep?

A

TCAs

279
Q

What medications increase REM sleep?

A

Cholinesterase inhibitors

280
Q

How do drugs affect REM sleep?

A

Via cholinergic neurons of thalamocortical arousal branch (part of ARAS)

281
Q

How can drugs lead to sleep related movement disorders?

A

Dopamine deficiency or antagonism via the hypothalamic aminergic arousal branch (part of ARAS)

282
Q

Impact of SSRIs on sleep

A

Increase SWS
Reduce REM

283
Q

Commonest sleep disorder in the elderly?

A

Insomnia

284
Q

Criteria for insomnia

A

Persist over 2 weeks
Contribute to impaired functioning

285
Q

Psychiatric disorders associated with insomnia

A

Mania
Depression
OCD
PTSD
PAnic disorders

286
Q

What type of sleep disorder is common in neurodegenerative disorders?

A

Insomnia with sleep fragentation

287
Q

What can REM sleep behaviour disorder be an early clinical marker for?

A

Synucleopathies

288
Q

Name the syncucleopathies

A

LBD
MSA
Parkinsons

289
Q

Treatment for insomnia

A

Short acting benzos
Z drugs
Melatonin agonists

290
Q

When should melatonin agonists be considered for insomnia?

A

> 55 age and sx lasting longer than 4 weeks

291
Q

Treatment for insomnia if it lasts for more than 2 weeks

A

Refer for CBT or other behaviour therapy

292
Q

Restriction of hypnotic use in insomnia

A

Only for patients who meet diagnostic criteria
Treatment duration M2 weeks

293
Q

When is circadian rhythm disorder more common in the elderly?

A

Nursing homes due to inadequate light exposure and immobility

294
Q

What contributes to circadian rhythm disorders in the elderly?

A

Degeneration of the suprachiasmatic nucleus

295
Q

Most common circadian rhythm disorder in the elderly?

A

Advanced sleep phase syndrome

296
Q

What happens in Advanced sleep phase syndrome?

A

Patients fall asleep several hours earlier and wake very early in the morning

297
Q

Treatment of circadian rhythm disorders

A

Bright light therapy
Early evening administration of melatonin
Chronotherapy

298
Q

What is chronotherapy?

A

Advancing sleep times gradually each day

299
Q

Which sleep disorder is associated with high morbidity and mortality?

A

Sleep hypopnea and apnoea

300
Q

What is needed to confirm diagnosis of OSA

A

Bed partner history
Polysomnography

301
Q

Treatment of OSA

A

Weight reduction
CPAP
Uvulopalatopharyngoplasty
Oral appliances

302
Q

In which disorders is there a higher prevalence of REM behaviour disorder

A

Parkinsons
MSA
LBD

303
Q

Prevalence of REM behaviour disorder in Parkinsons?

A

15-34%

304
Q

Prevalence of REM behaviour disorder in MSA?

A

90%

305
Q

Impact of age related oestrogen changes in women

A

Vaginal dryness and atrophy
Dyspaeunia

306
Q

What happens to testosterone levels in men?

A

Decrease after 5th decade

307
Q

How many men >70 have impotence?

A

10-20%

308
Q

Medical causes of sexual dysfunction

A

Parkinsons
CVE
Arthritis
Incontinence

309
Q

Drugs causing erectile dysfunction

A

EtOH
Benzos
Trazadone
Beta-blockers
Thiazide Diuretics
Spironlactone

310
Q

How many patients with Alzheimers show inappropriate sexual behaviour?

A

7%

311
Q

What can help when dealing with inappropriate sexual behaviour in dementia patients?

A

ABC system - antecedents, behaviour and consequences useful in understanding these behavioirs and creating interventions

312
Q

How many patients who lose a spouse meet the criteria for depression in the first month?

A

1/3

313
Q

How many patients who lose a spouse meet the criteria for depression after one year?

A

50%

314
Q

When should treatment for depression be given for those who have lost a spouse?

A

Suicidal ideation
Severe functional impairment
Prior hx of depression
Other signs of severe depression

315
Q

How many elderly patients develop signs of depression requiring treatment during first year of bereavement?

A

10-20%

316
Q

Who found that bereavement life events were more common in early onset depression?

A

Parkes
Grace and O’Brien

317
Q

Which age group is more likely to be depressed during the first month of widowhood?

A

Young

318
Q

How many elderly patients have depression in the second year of bereavement?

A

14%

319
Q

How many phases of grief?

A

4

320
Q

What is phase 1 of grief?

A

Shock and Protest

321
Q

What does phase 1 of grief involve?

A

Numbness
Disbelief
Acute dysphoria

322
Q

What is phase 2 of grief?

A

Preoccupation

323
Q

What does phase 2 of grief involve?

A

Yearning
Searching
Anger

324
Q

What is phase 3 of grief?

A

Disorganization

325
Q

What does phase 3 of grief involve?

A

Despair
Acceptance of loss

326
Q

What is phase 4 of grief?

A

Resolution

327
Q

When is improvement expected in normal grief?

A

2-6 months

328
Q

After what period of time should patients going through grief receive treatment?

A

Those who meet criteria for depression after 6 months

329
Q

Types of abnormal grief

A

Inhibited
Delayed
Chronic

330
Q

What happens in inhibited grief?

A

Absence of grief sx at any stage

331
Q

What happens in delayed grief?

A

Avoidance of painful sx within 2 weeks of loss

332
Q

What happens in chronic grief?

A

Continued significant grief related sx 6 months after loss

MRCPsych Part B (64 decks)

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