Old Age Psychiatry 1.2 Flashcards
What happens in Parkinsons?
Degeneration of subcortical structures: substantia nigra, caudate, putamen and globus pallidus
What type of disease is Parkinsons?
Subcortical degenerative diseases
What do Subcortical diseases effect?
Movement
Mood
Cognition
Which patients with Parkinsons are more likely to ave cognitive sx?
Those with late onset (>70)
How many patients with Parkinsons go on to develop dementia?
10%
What type of deficits are less severe in patients with LBD and Parkinsons vs Alzheimers?
Visual and verbal memory deficits
What type of deficits are more severe in LBD and Parkinsons vs Alzheimers?
Executive dysfunction:
planning, reasoning, sequencing
What neuropsychological impairments are noted in Parkinsons even if there is no cognitive impairment?
Visuospatial tasks
Impact of Parkinsons dementia?
Impairs QoL
Exacerbates carers distress
Increases likelihood if residential care
Doubles mortality
Most common SE of Levodopa or dopamine agonists
Visual hallucinations with insight
Treatment of psychosis secondary to medications
Reduce dose of levodopa or dopamine agonist
Clozapine/Quetiapine
Risk factors for developing psychosis in Parkinsons
Older age Longer duration of illness Dementia Severity of illness Sleep deprivation Use of dopamine agonists Polypharmacy
Criteria for diagnosis of LBD
If both motor sx and cognitive sx develop within 12 months
Criteria for diagnosis of Parkinsons dementia
If parkinsonian sx have existed for >12 months before dementia develops
How does SPECT differentiate between Parkinsons and LBD?
LBD shows greater caudate involvement
What is similar in SPECT of both Parkinsons and LBD?
Reduced perfusion of precuneus and parietal cortex - associated with visual processing
What does DAT scan detect?
Changes in dopamine transporter responsible for allowing brain cells to take up dopamine
What drug is licensed for treatment of Parkinsons Dementia?
Rivastigmine
What disorders come under FTD?
Picks
Primary progressive aphasia
Semantic dementia
Corticobasal degeneration
Age of onset of FTD
40-75
FTD accounts for how many cases of presenile dementia?
20%
Which chromosome is linked to FTD?
17
Early clinical features of FTD?
Personality
Behaviour
Which personality sx are seen in early FTD?
Disinhibition
Social misconduct
Lack of insight
Which behavioural sx are seen in early FTD?
Apathy
Mutism
Repetitive behaviours
What sx progress as FTD worsens?
Frontal and temporal dysfunction
Give e.g. of sx as FTD worsens
Behavioural rigidity Impulsivity Emotional lability Fatuosness Executive dysfunction Hyperorality
Memory impairment in FTD?
Memory is affected later and less severly
What cognition is well preserved in FTD?
Spatial orientation
What is characteristically lost early in FTD?
Insight
Pathological findings of FTD
Asymmetrical focal atrophy of frontotemporal regions
Underlying neuronal loss, gliosis and spongiform changes in affected cortices
What is FTD associated with?
MND
Treatment of FTD
SSRIs have limited benefit for behavioural sx
What do CT and MRI show in FTD?
Bilateral asymmetrical abnormalities of frontal and temporal lobes
What does SPECT show in FTD?
Disproportionate decrease in blood flow, radio tracer uptake and glucose metabolism in frontal lobe
What do neuropsychological tests show in FTD?
Impaired frontal lobe dysfunction: abstract thinking, attentional shifting, set formation
What functions are spared in FTS in neuropsychological testing?
Memory
Speech
Perceptuospatial functions
Onset of Picks disease
Slow
Steady deterioration
What sx show predominance of frontal lobe involvement in Picks?
Emotional blunting Coarsening of social behaviour Disinhibition Apathy/restlessness Non-fluent aphasia
What is preserved in early stage Picks disease?
Memory
Parietal lobe function
Onset of Picks
45-65 years
Gender ratio of Picks
Men more affected than women
Average duration of Picks
8 years
How many patients with Picks have a FHx?
50%
What causes Picks?
AD
Mutation in Tau gene with complete penetration
Where is the tau gene?
Chromosome 17q 21-22
What is pathognomic of Picks disease?
Picks cells
How do Picks cells appear?
Swollen and stain pain on H and E stains
What is absent in the pathology of Picks?
Senile plaques
Neurofibrillary tanges
What other pathology can be found in Picks?
Demyelination and fibrous gliosis of frontal lobe white matter
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
What happens in primary progressive aphasia?
Progressive decline in language with sparing of other cognitive deficits.
Speech in primary progressive aphasia?
Non-fluent and effortful
Poor output
Mute in later stages
MRI scan in primary progressive aphasia?
Predominant atrophy of perisylvian region
Speech in semantic dementia
Fluent
Impaired understanding of word meaning
Naming difficulties
Use of substitute words
MRI findings in semantic dementia
Disproportionate asymmetric atrophy of temporal lobe (more left)
Atrophy of anterior temporal lobe more pronounced than posterior temporal lobe
What type of dementia do most patients <65 years of age have?
Alzheimers
Which conditions are rarely seen in senile patients?
Progressive supranuclear Palsy
Corticobasal degeneration
Frontotemporal degeneration
In which types of early dementia are genetic abnormalities important?
Frontotemporal dementia with Parkinsonism - chromosome 17
Familial Alzheimers
Characteristics of early onset dementia?
Rapid progression of cognitive impairment with neuropsychological syndromes and neurological sx
What sx are common in early onset dementia?
Language problems
Visuospatial dysfunction
Which genes have been identified in familial Alzheimers with early onset?
Amyoid precursor gene - APP
Genes encoding PSEN1 and 2
Onset of Progressive Supranuclear Palsy
45-75 years
Presentation of PSP
Balance difficulties Abrupt falls Slurred speech Dysphagia Vague changes in personality Agitated depression
Most common early complaint in PSP?
Unsteadiness of gait and unexplained falling
Characteristic sx of PSP
Supranuclear opthalmoplegia
Pseudobulbar palsy
Axial dystonia
Vertical gaze palsy
What is vertical gaze palsy?
Difficulty in voluntary vertical movement of eyes
What is Bells phenomenon?
Reflexive upturning of eyes on forced closure of eyelids
Which eye movements are lost in PSP?
Vertical eye movements
Bells Phenomenon
Ability to converge
Dilatation of pupils
Characteristic eye expression of PSP
Upper eyelids retract
Wide-eyed, unblinking state imparting expression of perpetual surprise
What type of dementia occurs in PSP?
Subcortical
Sx of delirium
Rapid onset with fluctuations
Clouding of consciousness
Reduced attention span
Disturbance of sleep/wake cycle
Cognitive sx of delirium
Global impairment of cognition with disorientation and impairment of recent memory and abstract thinking
Sleep/wake cycle in delirium
Nocturnal worsening of sx
Speech in delirium
Rambling, incoherent and thought disordered
What characterises hyperactive delirium?
Increased motor activity
Agitation
Hallucinations
Inappropriate behaviour
What characterises hypoactive delirium?
Reduced motor activity
Lethargy
Which type of delirium has a poorer prognosis?
Hypoactive
Prevalence of delirium on admission to hospital
10-15% of elderly
Prevalence of delirium in the elderly during hospital
10-40%
Point prevalence of delirium in the general population
0.4%
Point prevalence of delirium in general hospital admissions
9-30%
Prevalence of delirium post-op
5-75%
Prevalence of delirium in ITU
12-50%
Prevalence of delirium in nursing homes
60%
Duration of delirium
Sudden onset
Lasts less than 1 week
Resolves quickly
Major pathway implicated in delirium?
Dosral tegmental pathway which projects from mesenchephalic reticular formation to tectum and thalamus
What is reticular formation of brainstem impottant for?
Regulating attention and arousal
Which neurotransmitter is involved in delirium?
Acetylcholine
EEG in delirium?
Generalised slowing of activity
What type of memory is impaired in delirium?
Recent and immediate
Sleep/wake cycle in delirium
Frequent disruption
Day/night reversal
Name the rating scales for delirium
Delirium rating scale - DRS
MMSE
CTD - cognitive test for delirium
CAM - confusion assessment method
Most widely used scale for delirium?
DRS
Advantage of DRS?
Distinguishes delirium from dementia
What is required for DRS use?
Interpretation by skilled clinician
Information from multiple clinical sources
What does MMSE emphasise?
Neuropsychological functions linked to left cerebral hemispheric activity
Problem of MMSE in use of delirium
Many of core features of delirium reflect non-dominant hemispheric functions
What does CTD allow?
Detailed investigation of range of neuropsychological functions
What patients is CTD useful for?
Patients whose ability to interact may by compromised
Which delirium rating scale has high sensitivity and specificity?
CAM
What does CAM allow?
Diagnosis of delirium
Incorporated into routine clinical settings
What can reduce sensitivity of CAM?
If used by nursing staff rather than physicians
Environmental support measures for delirium
Education Reorientation Reassurance Adequate lighting Reduce unnecessary noice Consistent staffing
Management of delirium
Environment
Regular clinical review and follow-up
Optimise hydration, nutrition, pain, sensory impairments
What test is useful for review of delirium and cognitive improvement
MMSE
Effective medication for delirium
Low dose haloperidol
NICE guidelines for medical management of delirium
<1 week use of Haloperidol or Olanzapine
When can benzos be useful in delirium?
If caused by withdrawal of alcohol or sedatives
Risks of benzo use in delirium?
Increases agitation
In elderly increases risk of falls and disinhibition
Prevalence of depression in >65 age group
10-15%
How much more common is depression in nursing homes?
2-3 times more common
Which medical conditions are associated with high risk of depression?
Cardiovascular disease
CNS disorders - stroke, dementia, Parkinsons
Cancer
How many people with dementia have depression?
25%
Ethnic variations in elderly with depression?
Elderly african americans have less rates of depression than elderly caucasians
Clinical features of depression in the elderly compared to young
Low mood may be less prevalent
More hypochondrical, somatic and delusional sx
Sx of depression in the elderly
Hypochondriasis and somatic concerns
Poor subjective memory
Late onset neurotic sx
Apathy and poor motivation
Cognitive impairment rates in those with depression in the elderly
70%
How many elderly patients with depression show psychomotor changes?
30%
What sx are more common in elderly depression?
Cognitive impairment Psychomotor changes Depressive delusions Paranoia and auditory hallucinations Weight loss Severe life stress
Risk factors for late-onset depression
Female
Poor health
Disability
Poor perceived social supported
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
CT findings in late onset depression
Cortical atrophy
Ventricular enlargement
MRI findings in late onset depression
Atrophy
Ventricular enlargement
Lesions in basal ganglia and white matter
SPECT findings in late onset depression
Reduced cerebral blood flow, sparing the posterior parietal cortex
NNT for antidepressant use in elderly
4 - similar to other age groups
Dosage of antidepressants in elderly with depression
Start at lower dose, but treatment dose should be same as for adults
First line treatment of late onset depression
SSRI
Recovery of late onset depression
Elderly take longer to recover - may take 6-8 weeks to respond to antidepressants
How many elderly patients do not respond to antidepressant medication for depression?
30%
Recovery rate of severe depression with ECT?
80%
SE of ECT in the elderly?
More likely to suffer from post ECT confusion and cognitive impairment
Memory impairment worse with bilateral electrode placement