Old Age Psychiatry 1.2 Flashcards
1
Q
What happens in Parkinsons?
A
Degeneration of subcortical structures: substantia nigra, caudate, putamen and globus pallidus
2
Q
What type of disease is Parkinsons?
A
Subcortical degenerative diseases
3
Q
What do Subcortical diseases effect?
A
Movement
Mood
Cognition
4
Q
Which patients with Parkinsons are more likely to ave cognitive sx?
A
Those with late onset (>70)
5
Q
How many patients with Parkinsons go on to develop dementia?
A
10%
6
Q
What type of deficits are less severe in patients with LBD and Parkinsons vs Alzheimers?
A
Visual and verbal memory deficits
7
Q
What type of deficits are more severe in LBD and Parkinsons vs Alzheimers?
A
Executive dysfunction:
planning, reasoning, sequencing
8
Q
What neuropsychological impairments are noted in Parkinsons even if there is no cognitive impairment?
A
Visuospatial tasks
9
Q
Impact of Parkinsons dementia?
A
Impairs QoL
Exacerbates carers distress
Increases likelihood if residential care
Doubles mortality
10
Q
Most common SE of Levodopa or dopamine agonists
A
Visual hallucinations with insight
11
Q
Treatment of psychosis secondary to medications
A
Reduce dose of levodopa or dopamine agonist
Clozapine/Quetiapine
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
13
Q
Criteria for diagnosis of LBD
A
If both motor sx and cognitive sx develop within 12 months
14
Q
Criteria for diagnosis of Parkinsons dementia
A
If parkinsonian sx have existed for >12 months before dementia develops
15
Q
How does SPECT differentiate between Parkinsons and LBD?
A
LBD shows greater caudate involvement
16
Q
What is similar in SPECT of both Parkinsons and LBD?
A
Reduced perfusion of precuneus and parietal cortex - associated with visual processing
17
Q
What does DAT scan detect?
A
Changes in dopamine transporter responsible for allowing brain cells to take up dopamine
18
Q
What drug is licensed for treatment of Parkinsons Dementia?
A
Rivastigmine
19
Q
What disorders come under FTD?
A
Picks
Primary progressive aphasia
Semantic dementia
Corticobasal degeneration
20
Q
Age of onset of FTD
A
40-75
21
Q
FTD accounts for how many cases of presenile dementia?
A
20%
22
Q
Which chromosome is linked to FTD?
A
17
23
Q
Early clinical features of FTD?
A
Personality
Behaviour
24
Q
Which personality sx are seen in early FTD?
A
Disinhibition
Social misconduct
Lack of insight
25
Which behavioural sx are seen in early FTD?
Apathy
Mutism
Repetitive behaviours
26
What sx progress as FTD worsens?
Frontal and temporal dysfunction
27
Give e.g. of sx as FTD worsens
Behavioural rigidity
Impulsivity
Emotional lability
Fatuosness
Executive dysfunction
Hyperorality
28
Memory impairment in FTD?
Memory is affected later and less severly
29
What cognition is well preserved in FTD?
Spatial orientation
30
What is characteristically lost early in FTD?
Insight
31
Pathological findings of FTD
Asymmetrical focal atrophy of frontotemporal regions
Underlying neuronal loss, gliosis and spongiform changes in affected cortices
32
What is FTD associated with?
MND
33
Treatment of FTD
SSRIs have limited benefit for behavioural sx
34
What do CT and MRI show in FTD?
Bilateral asymmetrical abnormalities of frontal and temporal lobes
35
What does SPECT show in FTD?
Disproportionate decrease in blood flow, radio tracer uptake and glucose metabolism in frontal lobe
36
What do neuropsychological tests show in FTD?
Impaired frontal lobe dysfunction: abstract thinking, attentional shifting, set formation
37
What functions are spared in FTS in neuropsychological testing?
Memory
Speech
Perceptuospatial functions
38
Onset of Picks disease
Slow
Steady deterioration
39
What sx show predominance of frontal lobe involvement in Picks?
Emotional blunting
Coarsening of social behaviour
Disinhibition
Apathy/restlessness
Non-fluent aphasia
40
What is preserved in early stage Picks disease?
Memory
Parietal lobe function
41
Onset of Picks
45-65 years
42
Gender ratio of Picks
Men more affected than women
43
Average duration of Picks
8 years
44
How many patients with Picks have a FHx?
50%
45
What causes Picks?
AD
Mutation in Tau gene with complete penetration
46
Where is the tau gene?
Chromosome 17q 21-22
47
What is pathognomic of Picks disease?
Picks cells
48
How do Picks cells appear?
Swollen and stain pain on H and E stains
49
What is absent in the pathology of Picks?
Senile plaques
Neurofibrillary tanges
50
What other pathology can be found in Picks?
Demyelination and fibrous gliosis of frontal lobe white matter
51
CT and MRI signs of Picks?
Mild generalised atrophy but marked atrophy of frontal and temporal lobs with sparing of posterior third of superior temporal gyrus - knife blade atrophy
52
What happens in primary progressive aphasia?
Progressive decline in language with sparing of other cognitive deficits.
53
Speech in primary progressive aphasia?
Non-fluent and effortful
Poor output
Mute in later stages
54
MRI scan in primary progressive aphasia?
Predominant atrophy of perisylvian region
55
Speech in semantic dementia
Fluent
Impaired understanding of word meaning
Naming difficulties
Use of substitute words
56
MRI findings in semantic dementia
Disproportionate asymmetric atrophy of temporal lobe (more left)
Atrophy of anterior temporal lobe more pronounced than posterior temporal lobe
57
What type of dementia do most patients <65 years of age have?
Alzheimers
58
Which conditions are rarely seen in senile patients?
Progressive supranuclear Palsy
Corticobasal degeneration
Frontotemporal degeneration
59
In which types of early dementia are genetic abnormalities important?
Frontotemporal dementia with Parkinsonism - chromosome 17
Familial Alzheimers
60
Characteristics of early onset dementia?
Rapid progression of cognitive impairment with neuropsychological syndromes and neurological sx
61
What sx are common in early onset dementia?
Language problems
Visuospatial dysfunction
62
Which genes have been identified in familial Alzheimers with early onset?
Amyoid precursor gene - APP
Genes encoding PSEN1 and 2
63
Onset of Progressive Supranuclear Palsy
45-75 years
64
Presentation of PSP
Balance difficulties
Abrupt falls
Slurred speech
Dysphagia
Vague changes in personality
Agitated depression
65
Most common early complaint in PSP?
Unsteadiness of gait and unexplained falling
66
Characteristic sx of PSP
Supranuclear opthalmoplegia
Pseudobulbar palsy
Axial dystonia
Vertical gaze palsy
67
What is vertical gaze palsy?
Difficulty in voluntary vertical movement of eyes
68
What is Bells phenomenon?
Reflexive upturning of eyes on forced closure of eyelids
69
Which eye movements are lost in PSP?
Vertical eye movements
Bells Phenomenon
Ability to converge
Dilatation of pupils
70
Characteristic eye expression of PSP
Upper eyelids retract
Wide-eyed, unblinking state imparting expression of perpetual surprise
71
What type of dementia occurs in PSP?
Subcortical
72
Sx of delirium
Rapid onset with fluctuations
Clouding of consciousness
Reduced attention span
Disturbance of sleep/wake cycle
73
Cognitive sx of delirium
Global impairment of cognition with disorientation and impairment of recent memory and abstract thinking
74
Sleep/wake cycle in delirium
Nocturnal worsening of sx
75
Speech in delirium
Rambling, incoherent and thought disordered
76
What characterises hyperactive delirium?
Increased motor activity
Agitation
Hallucinations
Inappropriate behaviour
77
What characterises hypoactive delirium?
Reduced motor activity
Lethargy
78
Which type of delirium has a poorer prognosis?
Hypoactive
79
Prevalence of delirium on admission to hospital
10-15% of elderly
80
Prevalence of delirium in the elderly during hospital
10-40%
81
Point prevalence of delirium in the general population
0.4%
82
Point prevalence of delirium in general hospital admissions
9-30%
83
Prevalence of delirium post-op
5-75%
84
Prevalence of delirium in ITU
12-50%
85
Prevalence of delirium in nursing homes
60%
86
Duration of delirium
Sudden onset
Lasts less than 1 week
Resolves quickly
87
Major pathway implicated in delirium?
Dosral tegmental pathway which projects from mesenchephalic reticular formation to tectum and thalamus
88
What is reticular formation of brainstem impottant for?
Regulating attention and arousal
89
Which neurotransmitter is involved in delirium?
Acetylcholine
90
EEG in delirium?
Generalised slowing of activity
91
What type of memory is impaired in delirium?
Recent and immediate
92
Sleep/wake cycle in delirium
Frequent disruption
Day/night reversal
93
Name the rating scales for delirium
Delirium rating scale - DRS
MMSE
CTD - cognitive test for delirium
CAM - confusion assessment method
94
Most widely used scale for delirium?
DRS
95
Advantage of DRS?
Distinguishes delirium from dementia
96
What is required for DRS use?
Interpretation by skilled clinician
Information from multiple clinical sources
97
What does MMSE emphasise?
Neuropsychological functions linked to left cerebral hemispheric activity
98
Problem of MMSE in use of delirium
Many of core features of delirium reflect non-dominant hemispheric functions
99
What does CTD allow?
Detailed investigation of range of neuropsychological functions
100
What patients is CTD useful for?
Patients whose ability to interact may by compromised
101
Which delirium rating scale has high sensitivity and specificity?
CAM
102
What does CAM allow?
Diagnosis of delirium
Incorporated into routine clinical settings
103
What can reduce sensitivity of CAM?
If used by nursing staff rather than physicians
104
Environmental support measures for delirium
Education
Reorientation
Reassurance
Adequate lighting
Reduce unnecessary noice
Consistent staffing
105
Management of delirium
Environment
Regular clinical review and follow-up
Optimise hydration, nutrition, pain, sensory impairments
106
What test is useful for review of delirium and cognitive improvement
MMSE
107
Effective medication for delirium
Low dose haloperidol
108
NICE guidelines for medical management of delirium
<1 week use of Haloperidol or Olanzapine
109
When can benzos be useful in delirium?
If caused by withdrawal of alcohol or sedatives
110
Risks of benzo use in delirium?
Increases agitation
In elderly increases risk of falls and disinhibition
111
Prevalence of depression in >65 age group
10-15%
112
How much more common is depression in nursing homes?
2-3 times more common
113
Which medical conditions are associated with high risk of depression?
Cardiovascular disease
CNS disorders - stroke, dementia, Parkinsons
Cancer
114
How many people with dementia have depression?
25%
115
Ethnic variations in elderly with depression?
Elderly african americans have less rates of depression than elderly caucasians
116
Clinical features of depression in the elderly compared to young
Low mood may be less prevalent
More hypochondrical, somatic and delusional sx
117
Sx of depression in the elderly
Hypochondriasis and somatic concerns
Poor subjective memory
Late onset neurotic sx
Apathy and poor motivation
118
Cognitive impairment rates in those with depression in the elderly
70%
119
How many elderly patients with depression show psychomotor changes?
30%
120
What sx are more common in elderly depression?
Cognitive impairment
Psychomotor changes
Depressive delusions
Paranoia and auditory hallucinations
Weight loss
Severe life stress
121
Risk factors for late-onset depression
Female
Poor health
Disability
Poor perceived social supported
122
Neuroimaging findings in late onset depression
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
123
CT findings in late onset depression
Cortical atrophy
Ventricular enlargement
124
MRI findings in late onset depression
Atrophy
Ventricular enlargement
Lesions in basal ganglia and white matter
125
SPECT findings in late onset depression
Reduced cerebral blood flow, sparing the posterior parietal cortex
126
NNT for antidepressant use in elderly
4 - similar to other age groups
127
Dosage of antidepressants in elderly with depression
Start at lower dose, but treatment dose should be same as for adults
128
First line treatment of late onset depression
SSRI
129
Recovery of late onset depression
Elderly take longer to recover - may take 6-8 weeks to respond to antidepressants
130
How many elderly patients do not respond to antidepressant medication for depression?
30%
131
Recovery rate of severe depression with ECT?
80%
132
SE of ECT in the elderly?
More likely to suffer from post ECT confusion and cognitive impairment
Memory impairment worse with bilateral electrode placement
133
Evidence of psychological therapy for depression in the elderly
Just as effective as medication for mild-moderate depression
134
What is best treatment for relapse prevention of depression in the elderly?
Combination of medication and therapy
135
Best therapies for depression in the elderly?
CBT
Interpersonal therapy
Problem solving treatment
Family therapy
136
Relapse rates in elderly with depression compared to adults?
Higher relapse rates in the elderly
137
Mortality of elderly with depression?
Higher due to physical disorders
138
Good prognostic factors for late onset depression
Onset <70 years of age
Short duration of illness
Absent physical illness
Good previous recovery
Good previous adjustment
139
Poor prognostic factors for late onset depression
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
Depression and MI in the elderly
Elderly individuals with depression were 4x more likely to die within 4 months of MI
141
Link between MI and depression in the elderly?
Platelet aggregation raised in patients with depression
142
Link between fractures and depression in the elderly?
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
Depression scales for the elderly
Geriatric depression scale
BASDEC
Hamilton
MADRS
Depressive sign scale
CSDD
PHQ 9
144
How many items in Geriatric depression scale?
15
145
How long does geriatric depression scale take to complete?
4-5 minutes
146
Scoring in geriatric depression scale?
>5 suggests depressive illness
147
Advantage of geriatric depression scale?
Avoids somatic sx
148
What does BASDEC stand for?
Brief assessment schedule depression cards
149
What is BASDEC?
Series of statements in large print on cards which are shown to patients; answer T/F
150
Why is Hamilton not as appropriate for the elderly?
Somatic items
151
What does MADRS stand for?
Montgomery-Asberg depression rating scale
152
Advantages of MADRS
Sensitive to change in depression
153
Disadvantages of MADRS
Not reliably answered by patients with dementia
154
What does Depressive sign scale consist of?
9 items
155
Advantage of depressive sign scale?
Helps detect depression in people with dementia
156
What does CSDD stand for?
Cornell scale for depression in dementia
157
What is the best validated scale for detecting depression in dementia patients?
CSDD
158
How does CSDD work?
Interviewer-administered
Using info from both patient and an informant
159
Factors involved in CSDD
General depression
Biologic rhythm disturbances
Agitation/psychosis
Negative sx
160
How many items in PHQ 9?
9
Self-report
161
Advantages of PHQ 9
Easy to use
Sensitive to change
162
Cognitive impairment in late onset depression
Specific deficits in attention and executive function, consistent with frontal lobe dysfunction
163
Cognitive deficits in early onset depression
Deficits in episodic memory - consistent with temporal lobe dysfunction
164
What is pseudodementia?
When patients develop dementia during episodes of depression that subsides after remission of depression
165
How many patients with pseudodementia develop true dementia within 3 years?
40%
166
Sx duration of pseudodemtnia vs dementia
Pseudodementia: short duration
Dementia; long duration
167
Sx progression in pseudodementia vs dementia
Pseudodementia: rapid progression
Dementia: slow progression
168
Attention and concentration in pseudodementia vs dementia
Pseudodementia: preserved attention and concentration
Dementia: not well preserved
169
Memory loss in pseudodementia vs dementia
Pseudodementia: memory loss for recent and remote events, severe
Dementia: memory loss for recent events more severe than for remote events
170
Who suggested that vascular depression was a subtype of geriatric depression?
Alexopoulous
171
Pathology underlying vascular depression
Cerebral ischaemic damage to frontal subcortical circuits could lead to late onset depression
172
Clinical features of vascular depression
Apathy
Psychomotor retardation
Poor executive function
Less depressive thinking
Late age of onset
173
Features of vascular depression which are not as common in late onset depressino
Apathy
Retardation
Lack of insight
Less agitation and guilt
174
Most impaired cognitive functions in vascular depression?
Verbal fluency
Object naming
175
Theories explaining association depression and vascular disease
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
What is more common in MRI of depressed elderly than non-depressed elderly?
White matter lesions
177
What do white matter lesions on MRI in depressed elderly patients correlate with?
Poorer response to treatment of depression
178
Who studied the associatino between subcortical lesions and antidepressant response in late onset depression?
Simpson et al
179
What did Simpson et al's study show?
Poor response to antidepressants in patients with vascular depression
Drugs used for prevention of CVD might reduce risk of vascular depression
180
Which antidepressants promote ischaemic recovery?
Dopamine or norepinephrine enhancing agents
181
Which antidepressants inhibit ischaemic recovery?
Adrenergic blocking agents
182
What % of mood disorders in the elderly are due to mania?
5-10%
183
One year prevalence of bipolar among adults >65?
0.4%
184
Difference in mania in the elderly?
More often followed by a depressive episode
Mixed affective presentations are more common
185
What are patients with first episode mania in late life at risk of?
Twice as likely to have comorbid neurological disorder.
186
Cognitive function in late onset mania
Cognitive function is significantly impaired between a fifth and third of elderly patients
187
Imaging study findings in elderly with late life mania
High rate of cerebral white matter lesions
188
What is secondary mania?
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
Which conditions are associated with secondary mania?
Stroke - mainly right-sided lesions
HI
Tumours
Endocrine infections
HIV
Medications
190
Which drugs can cause mania?
Steroids
Anti-Parkinson drugs
191
Treatment of mania in the elderly
Lithium but at lower doses
Valproate
Antipsychotics in severe illness
192
Therapeutic range for prophylaxis of mania in the elderly?
0.4-0.6
193
When are psychotic sx commonly seen in the elderly?
Delirium due to medical condition
Drug misuse
Drug-induced psychosis
194
What neurodegenerative conditinos can cause psychosis?
Alzheimers
Vascular Dementia
LBD
Parkinsons
195
Who coined the term paraphrenia?
Kraepelin in 1913
196
What is paraphrenia?
Late life psychosis
197
What are the two points of view of paraphrenia?
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
What is late onset psychosis divided into?
Late onset >40 years
Very late onset >60 years
199
What % of the elderly population in psychiatric hospital have late onset psychosis?
10%
200
Prevalence of late onset psychosis in the community
0.1-4%
201
Incidence of late onset psychosis
10-26 per 100,000 per year
202
Point prevalence of paranoid ideation in the elderly population?
4-6%
203
Gender differences in late onset psychosis
More females affected
204
Most common feature of late onset psychosis
Persecutory delusions
205
How many patients with late onset psychosis have persecutory delusions?
90%
206
How many patients with late onset psychosis have auditory hallucinations?
75%
207
How many patients with late onset psychosis have visual hallucinations?
60%
208
What sx are less common in late onset psychosis?
First rank
Negative sx
Thought disorders
209
How many patients with late onset psychosis present with delusions only?
10-20%
210
What type of delusions are common in late onset psychosis?
Persecutory
Partition delusions
211
What are partition delusions?
Attack through the wall or ceiling is passed through by a person, radiation/gas or neighbours spying via a partition
212
ICD diagnosis of paraphrenia?
No such diagnosis
Patients must be diagnosed either with schizophrenia or delusional disorder
213
What characterises late onset psychosis?
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
Risk of tardive dyskinesia in the elderly on antipsychotics?
Increased 5-6 times
215
Relatives of very late onset psychosis vs relatives of early onset?
Relatives of very late onset have lower morbid risk for schizophrenia
216
Prevalence of schizophrenia in siblings
7%
217
Prevalence of schizophrenia in parents
3%
218
What is less impaired in late onset psychosis?
Premorbid educational, occupational and psychosocial functioning
219
What personality traits are noted in people with late onset psychosis?
Premorbid schizoid or paranoid personality traitrs
220
Risk factors for late onset psychosis
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
What must be excluded before antipsychotics can be used in late onset psychosis?
LBD
222
Which antipsychotics are considered more suitable for the elderly?
Atypical
223
Advice re starting antipsychotics in the elderly
Start low
Go slow
224
What does research suggest re use of conventional antipsychotics in the elderly?
Significant improvement with haloperidol and trifluoperazine
225
Risks of clozapine use in the elderly
Toxicity
More frequent occurrence of agranulocytosis
226
What factors may contribute to neurotic sx in the elderly?
Physical frailty
Major life events
Bereavement
Social isolation
Poor self-care
Insecure personality
227
Prevalence of neurotic disorders in the elderly?
1-10%
228
Most prevalent psychiatric disorder in >65
Anxiety
229
Correlation between anxiety and age?
Prevalence of anxiety disorders decreases with age
230
Most prevalent anxiety disorder in the elderly?
Phobic disorders
231
Least common anxiety disorder in the elderly?
Panic disorder
232
What anxiety sx dominate in the elderly?
Hypochondriacal and depressive sx
233
What sx are less common in the elderly with anxiety?
Obsessional, phobic, dissociative and conversion disorders
234
What is a common response to anxiety in the elderly?
Sedative drugs
Alcohol
235
What are most cases of agoraphobia in the elderly a result of?
Alarming experience of physical ill health
236
What do patients need to be warned about when starting medication for anxiety
Transient increase in anxiety in first 1-2 weeks
237
What medications should be used for GAD?
Fluoxetine
Paroxetine
Venlafaxine
238
What medications should be used for panic disorder?
Citalopram
239
What medications should be used for PTSD?
Fluoxetine
Paroxetine
240
Why are the elderly likely to encounter alcohol disorders at lower intake levels than the general population?
Effects of physical and cognitive ageing
Pharmacokinetic changes
Increased prevalence of co-morbid illness
Interactions with medications
241
Alcohol misuse in males vs females
Men are twice as likely to exceed safe drinking limits
Women report more late onset alcohol problems
242
Which men are at increased risk of heavy drinking?
Widowed or divorced
243
Which older women are at increased risk of alcohol misuse?
Married
244
Features of early onset alcohol misuse
Lifelong pattern of problem drinking
FHx of alcoholism
245
Age of onset of alcohol misuse in early onset?
20-30
246
Age of onset of alcohol misuse in late osnet
40-50 years
247
Features of late onset alcohol misuse
Fewer physical and MH problems
Stressful life event as precipitator
More receptive to treatment
248
Medications used to reduce relapse in alcohol misuse
Disulfiram
Acamprosate
Naltrexone
249
Why do some studies suggest disulfiram should not be used in the elderly?
Increased risk of serious adverse effects such as acute confusion.
250
Contraindications of disulfiram?
Hx of HTN, CCF, CVE or IHD
251
Lifetime prevalence of drug misuse in the elderly
1.6%
252
Most commonly prescribed psychotropic drug in the elderly?
Benzos
253
Risk of suicide and age
Incidence of DSH goes down with risk
Completed suicide rises with age
Suicidal intent behind acts of DSH greater in the elderly
254
Most common method of DSH in the elderly
OD
255
Most common drugs used in OD in the elderly
Benzos
Analgesics
Antidepressants
256
Psychiatric disorders in elderly who DSH
Depression - half
Alcohol abuse - one third
257
Risk factors for DSH in the elderly
Physical illness
Widowhood/divorced/separation
Social isolation
Living alone
Unresolved grief
258
How many elderly patients who died from suicide had depression?
70%
259
What sx of depression are associated with suicide in the elderly?
Chronic sx of depression
First depressive illness in later life
Inadequately treated depression
Co-morbid physical illness
260
Social risk factors for suicide in the elderly?
Social isolation
Lack of support
Concerns over dependents
Move from home to residential care
Grief reaction greater than one year
261
What did the Monroe County sample find re the elderly and suicide (>50 years)?
Suicide was associated with higher levels or Neuroticism and lower scores on openness to experience
262
What did Harwood and colleagues found in patients >60 who committed suicide?
Anankastic and anxious traits were associated with both depression and suicidality in the elderly
263
Prevalence of PDs in the elderly
5-10%
264
Which personality traits increase wit age?
Cautiousness
Obsessionality
Compulsive Traits
Introversion
265
Which traits 'burn out' with age?
Psychopathy
Criminal behaviour
266
Which PD has reduced prevalence in the elderly?
Antisocial
Histrionic
267
Which PD has the highest prevalence in the elderly?
OCD
268
Prevalence of OCD PD in the elderly?
3.3%
269
Links between elderly with PD and other MI?
Patients with PD are 4x more likely to have depression or GAD
270
Which personality traits are likely to occur in patients with depression irrespective of age?
Avoidant
Dependant
Compulsive
271
How many patients with dementia report negative personality change?
2/3
272
What patterns of personality change are reported in patients with organic disorders?
Alteration at onset of dementia with little subsequent change
Ongoing change with disease progression
Regression to previously disturbed behaviours
No change
273
What is Diogenes syndrome?
Self-neglect in older people in which eccentric and reclusive individuals become increasingly isolated and neglect themselves.
274
Characteristics of patients with Diogenes syndrome?
Oblivious to their condition
Resistant to help
Hoarding (syllogomania)
275
Sleep changes in the elderly?
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
What is insomnia in the elderly associated with?
Depression
Heart disease
Pain
Memory problems
277
Which sleep disorders are common in the eldrely?
Insomnia
Circadian rhythm disorders
RLS
REM sleep behaviour disorder
OSA
278
What medications reduce REM sleep?
TCAs
279
What medications increase REM sleep?
Cholinesterase inhibitors
280
How do drugs affect REM sleep?
Via cholinergic neurons of thalamocortical arousal branch (part of ARAS)
281
How can drugs lead to sleep related movement disorders?
Dopamine deficiency or antagonism via the hypothalamic aminergic arousal branch (part of ARAS)
282
Impact of SSRIs on sleep
Increase SWS
Reduce REM
283
Commonest sleep disorder in the elderly?
Insomnia
284
Criteria for insomnia
Persist over 2 weeks
Contribute to impaired functioning
285
Psychiatric disorders associated with insomnia
Mania
Depression
OCD
PTSD
PAnic disorders
286
What type of sleep disorder is common in neurodegenerative disorders?
Insomnia with sleep fragentation
287
What can REM sleep behaviour disorder be an early clinical marker for?
Synucleopathies
288
Name the syncucleopathies
LBD
MSA
Parkinsons
289
Treatment for insomnia
Short acting benzos
Z drugs
Melatonin agonists
290
When should melatonin agonists be considered for insomnia?
>55 age and sx lasting longer than 4 weeks
291
Treatment for insomnia if it lasts for more than 2 weeks
Refer for CBT or other behaviour therapy
292
Restriction of hypnotic use in insomnia
Only for patients who meet diagnostic criteria
Treatment duration M2 weeks
293
When is circadian rhythm disorder more common in the elderly?
Nursing homes due to inadequate light exposure and immobility
294
What contributes to circadian rhythm disorders in the elderly?
Degeneration of the suprachiasmatic nucleus
295
Most common circadian rhythm disorder in the elderly?
Advanced sleep phase syndrome
296
What happens in Advanced sleep phase syndrome?
Patients fall asleep several hours earlier and wake very early in the morning
297
Treatment of circadian rhythm disorders
Bright light therapy
Early evening administration of melatonin
Chronotherapy
298
What is chronotherapy?
Advancing sleep times gradually each day
299
Which sleep disorder is associated with high morbidity and mortality?
Sleep hypopnea and apnoea
300
What is needed to confirm diagnosis of OSA
Bed partner history
Polysomnography
301
Treatment of OSA
Weight reduction
CPAP
Uvulopalatopharyngoplasty
Oral appliances
302
In which disorders is there a higher prevalence of REM behaviour disorder
Parkinsons
MSA
LBD
303
Prevalence of REM behaviour disorder in Parkinsons?
15-34%
304
Prevalence of REM behaviour disorder in MSA?
90%
305
Impact of age related oestrogen changes in women
Vaginal dryness and atrophy
Dyspaeunia
306
What happens to testosterone levels in men?
Decrease after 5th decade
307
How many men >70 have impotence?
10-20%
308
Medical causes of sexual dysfunction
Parkinsons
CVE
Arthritis
Incontinence
309
Drugs causing erectile dysfunction
EtOH
Benzos
Trazadone
Beta-blockers
Thiazide Diuretics
Spironlactone
310
How many patients with Alzheimers show inappropriate sexual behaviour?
7%
311
What can help when dealing with inappropriate sexual behaviour in dementia patients?
ABC system - antecedents, behaviour and consequences useful in understanding these behavioirs and creating interventions
312
How many patients who lose a spouse meet the criteria for depression in the first month?
1/3
313
How many patients who lose a spouse meet the criteria for depression after one year?
50%
314
When should treatment for depression be given for those who have lost a spouse?
Suicidal ideation
Severe functional impairment
Prior hx of depression
Other signs of severe depression
315
How many elderly patients develop signs of depression requiring treatment during first year of bereavement?
10-20%
316
Who found that bereavement life events were more common in early onset depression?
Parkes
Grace and O'Brien
317
Which age group is more likely to be depressed during the first month of widowhood?
Young
318
How many elderly patients have depression in the second year of bereavement?
14%
319
How many phases of grief?
4
320
What is phase 1 of grief?
Shock and Protest
321
What does phase 1 of grief involve?
Numbness
Disbelief
Acute dysphoria
322
What is phase 2 of grief?
Preoccupation
323
What does phase 2 of grief involve?
Yearning
Searching
Anger
324
What is phase 3 of grief?
Disorganization
325
What does phase 3 of grief involve?
Despair
Acceptance of loss
326
What is phase 4 of grief?
Resolution
327
When is improvement expected in normal grief?
2-6 months
328
After what period of time should patients going through grief receive treatment?
Those who meet criteria for depression after 6 months
329
Types of abnormal grief
Inhibited
Delayed
Chronic
330
What happens in inhibited grief?
Absence of grief sx at any stage
331
What happens in delayed grief?
Avoidance of painful sx within 2 weeks of loss
332
What happens in chronic grief?
Continued significant grief related sx 6 months after loss
