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Psychiatry > Old age psychiatry > Flashcards

Old age psychiatry Flashcards

1
Q

frequency of dementia

A

1 in 5 of the population

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2
Q

Cut off score in cognitive tests

A

AMTS - 8/10
MMSE- 24/30
MoCA- 24/30

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3
Q

Questions in the AMTS

A
  1. What is your age?
  2. What is the time to the nearest hour?
  3. Give the patient an address, and ask him or her to repeat it at the end of the test
    e.g. 42 West Street
  4. What is the year?
  5. What is the name of the hospital or number of the residence where the patient is
    situated?
  6. Can the patient recognize two persons (the doctor, nurse, home help, etc.)?
  7. What is your date of birth? (day and month sufficient)
  8. In what year did World War 1 begin?
  9. Name the present monarch/prime minister/president.
  10. Count backwards from 20 down to 1.
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4
Q

signs of dementia on CT

A

ventricular dilatation
sulcal widening
assymmetrical bilateral hippocampal atrophy

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5
Q

ICD-10 definition of dementia

A
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6
Q

what domains are affected in dement a

A

Cognitive
memory
orientation
visuo-spacial
language
executave (planning, organising, problem solving)

non-cog
behavioural symptoms (agitation, wandering , apathy)
psychotic symptoms - (delusions, hallucinations usually visual)
affective mood disorders (depression)
change in emotion, personality, behaviour

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7
Q

epidemiology of dementia

A

7% people over 65
20% over 80
850,000 in UK
40,000 <65
1/3 never get diagnosed

75% alzheimers
15% vascular
10% Lewy body
2% frontotemporal

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8
Q

Alzheimers

A

insidious onset
progressive cognitive decline
gradual loss of function

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9
Q

Vascular dementia features

A

abrupt onset
stepwise deterioration
fluctuation course
RFs: diabetes, HPTN, obesity, AF!!
focal neurological signs
patchy deficits

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10
Q

Lewy body

A

Parkinsonism
fluctuating cognitive impairments (can be dramatic changes from doing a crossword to not being able to tell you their name)
visual hallucinations - but no emotional connection. (LILLIPUTIAN hallucinations- little people or animals)
falls
nighttime disturbance (REM sleep disorder, acting out in sleep)
sensitivity to antipsychotics

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11
Q

principles of dementia diagnosis

A

exclude mimic conditions
- depression (psuedo dementia), delusions, thyroid

figure out cause/ type of dementia

RISK ASSESSMENT
- driving/DVLA, self-neglect, exploitation

Assess capacity
-LPA, wills

Counseling and education to pt and family

regular reviews with an MDT

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12
Q

Investigations for dementa

A

History from patient and collateral
cognitive assessment
physical assessment - eg undetected pain/ discomfort, constipation, SE of medication
alcohol consumption
Bloods: FBC, U&Es, calcium, LFTs, TFTs, B12, lipids
ECG
MRI/CT scans if appropriate

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13
Q

DDx of dementa

A

mild cognitive disorder (no effect on executive function eg. driving, cooking)
depression
delerium
dysphasia
LD
psychotic disorder
iatrogenic

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14
Q

Treatment of dementia

A

AntiCholinesterase inhibitors
- donepezil(10mg), rivastigmine(6mg BD)-+++adverse affects, galantamine
-improve baseline

NMDA antagonist
- memantine

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15
Q

drugs to avoid in dementia

A

non-selective antihistamines
-promethazine, chlorphenamine

anticholinergic
- procyclidine

antipsychotics- increases chance of death. especially haloperidol

SSRIs- increases chance of falls, hyponatraemia

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16
Q

Conditions that can present with dementia

A

Depression
Creutzfelt jakobs disease
Picks disease (frontotemporal)
Parkinsons
Huntingtons
B12 deficiency
Neurosiphilis
normal pressure hydrocephalus

17
Q

features of delerium

A

-disturbance in attention and awareness
-can be additional disturbances in cognition
-develops quickly and tends to fluctuate during the day
- direct consequence of a medical condition

18
Q

high risk people

A

Elderly
pts with dementia
post op
burns
alcohol and benzo dependence
severely ill

19
Q

Delerium investigations

A

MSE
MoCA/ AMSE
Find the cause:
- pain
- dehydration status
- bowel habits (consitipation)
-medication review eg. opiates
- UTI, wound infections, infection elsewhere (FBC, CRP, urinanalysis, lactate)

20
Q

Key questions for delerium

A
  • whats happened- collateral from family and staff
  • any fluctuations
  • aware of surrounding, orientation to time, date, place
  • recognition of care givers, family
  • what time of the day is it
  • sensitive to environmental changes
  • quieter/ less attentive
  • explore any underlying medical conditions (PMHx)
  • bowel movements, urinary symptoms
  • comorbid psychiatric symptoms- mood, sleep, perception, thought abnormalities (MSE)
21
Q

Potential causes of delerium

A

Infection: UTI, pneumonia, wound infection etc
Metabolic: anaemia, electrolyte disturbances, hepatic encephalitis, uraemia, CF, hypothermia
intracranial: CVA, encephalitis, brainy mets, raised ICP
Endocrine : pituitary, thyroid, parathyroid, adrenals
Substances: alcohol, benzo withdrawal, steroids, anticholinergics, psychotropic, lithium, anti-HPTN, diuretics, anticonvulsants, digoxin, NSAIDS
Hypoxia: COPD, asthma

22
Q

DDx for delerium

A

mood disorder
psychotic illness
post-ictal state
dementia

23
Q

Management of delirious pt

A
  • establish the underlying cause
  • provide environmental and supportive measures (educate those interacting with pt, minimise moving, clocks, natural lighting, reduce noise, make environment safe , correct sensory impairment eg. glasses, hearing aids)
  • avoid sedation (rule of thumb if before midnight don’t give any sedatives. only give if absolutely necessary ie in middle of night and disturbing other pts) Most commonly used is haloperidol
  • regular clinical reviews
24
Q

features of delerium tremens

A

Hx of alcohol abuse (>10units daily for prev 10 days)
72 hrs after last drink (can happen between 1-7 days)
acute confusional state
visual, auditory and tactile hallucinations (lilliputian- little people, insects crawling all over them)
physical symptoms eg. sweating, coarse tremor, insomnia, tachycardia, N&V
fluctuations in symptoms
fear, paranoia, agitation

25
Q

management of delerium trement

A

acute medical emergency
can kill –> seizures
admit to medical team
lorazepam

26
Q

types of delerium

A

hyperactive - jumping about, disrupting
hypoactive - negative sx, not talking, not getting in bed
mixed form

27
Q

difference between delerium and dementia

A

Delerium
- acute, fluctuating, impaired awareness, poor working memory and immediate recall, short lived or changing delusions, reversible

dementia
- insidious, gradual deterioration, often retained awareness and attention, poor short term memory, fixed delusions, not reversible

28
Q

general investigations for elderly psych

A

Bedside: neuro exam, urine dip, urine drug screen
Bloods: FBC, U&Es, LFTs, LFTs, TFTs, HbA1c, B12, folate, Ca, syphilis, HIV
Imaging: CXR, MRI/CT head

29
Q

General management of elderly psych

A

bio
treat medical cause, correct hearing/eyesignt. medication review
CBT, supportive, psychotherapy, HTT referral
Safeguarding, environment, keysafe, carers, home visits, risk management

30
Q

Treatment for elderly depression

A

antidepressants unless cognitively impaired as
increased risk of adverse effects (eg. falls, hyponatraemia, CVA)

sertraline or mirtazapine first line

ECT in severe and life threatening depression

31
Q

psychotic depression

A

mood congruent
guilt
nihilistic delusions (im rotting away)

Rx with antidepressant with antipsychotic
ECT if severe

32
Q

organic cause of mania

A

brain tumour, CVA
new course of steroids
hyperthyroidism - (eg. elderly forgotten to take antithyroid drugs)
drugs eg cocaine

33
Q

late onset schizophrenia RFs and treatment

A

rare but dont rule out in old person with delusions/ psychotic symptoms
RFs: female, sensory impairments, social isolation, poor social functioning

Rx: antipsychotics- start low go slow
risks of EPSE, falls, cardiac effects (long QTc), sedation, hyperprolactinaemia, osteoporosis
increased risk of death

–> amisulpride, olanzapine, risperidone

34
Q

Alcohol missuse risks

A

withdrawal- seizures and delerium tremens
alcohol related dementia
wernick-Korsakoff syndrome
reduced life expectancy

30% alcohol related admissions

35
Q

Differentiate between wernikes and korsakoffs

A

Wernickes encephalopathy- Acute phase brain disorder resulting from thiamine deficiency
classical triad of confusion, oculomotor dysfunction, and gait ataxia
usually a result of alcohol excess

Korsakoffs- irreversible chronic syndrome characterised by antegrade and retrograde amnesia, confabulations, personality changes

Psychiatry (4 decks)

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