Old age psychiatry Flashcards
frequency of dementia
1 in 5 of the population
Cut off score in cognitive tests
AMTS - 8/10
MMSE- 24/30
MoCA- 24/30
Questions in the AMTS
- What is your age?
- What is the time to the nearest hour?
- Give the patient an address, and ask him or her to repeat it at the end of the test
e.g. 42 West Street - What is the year?
- What is the name of the hospital or number of the residence where the patient is
situated? - Can the patient recognize two persons (the doctor, nurse, home help, etc.)?
- What is your date of birth? (day and month sufficient)
- In what year did World War 1 begin?
- Name the present monarch/prime minister/president.
- Count backwards from 20 down to 1.
signs of dementia on CT
ventricular dilatation
sulcal widening
assymmetrical bilateral hippocampal atrophy
ICD-10 definition of dementia
what domains are affected in dement 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
epidemiology of dementia
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
Alzheimers
insidious onset
progressive cognitive decline
gradual loss of function
Vascular dementia features
abrupt onset
stepwise deterioration
fluctuation course
RFs: diabetes, HPTN, obesity, AF!!
focal neurological signs
patchy deficits
Lewy body
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
principles of dementia diagnosis
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
Investigations for dementa
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
DDx of dementa
mild cognitive disorder (no effect on executive function eg. driving, cooking)
depression
delerium
dysphasia
LD
psychotic disorder
iatrogenic
Treatment of dementia
AntiCholinesterase inhibitors
- donepezil(10mg), rivastigmine(6mg BD)-+++adverse affects, galantamine
-improve baseline
NMDA antagonist
- memantine
drugs to avoid in dementia
non-selective antihistamines
-promethazine, chlorphenamine
anticholinergic
- procyclidine
antipsychotics- increases chance of death. especially haloperidol
SSRIs- increases chance of falls, hyponatraemia
Conditions that can present with dementia
Depression
Creutzfelt jakobs disease
Picks disease (frontotemporal)
Parkinsons
Huntingtons
B12 deficiency
Neurosiphilis
normal pressure hydrocephalus
features of delerium
-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
high risk people
Elderly
pts with dementia
post op
burns
alcohol and benzo dependence
severely ill
Delerium investigations
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)
Key questions for delerium
- 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)
Potential causes of delerium
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
DDx for delerium
mood disorder
psychotic illness
post-ictal state
dementia
Management of delirious pt
- 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
features of delerium tremens
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
management of delerium trement
acute medical emergency
can kill –> seizures
admit to medical team
lorazepam
types of delerium
hyperactive - jumping about, disrupting
hypoactive - negative sx, not talking, not getting in bed
mixed form
difference between delerium and dementia
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
general investigations for elderly psych
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
General management of elderly psych
bio
treat medical cause, correct hearing/eyesignt. medication review
CBT, supportive, psychotherapy, HTT referral
Safeguarding, environment, keysafe, carers, home visits, risk management
Treatment for elderly depression
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
psychotic depression
mood congruent
guilt
nihilistic delusions (im rotting away)
Rx with antidepressant with antipsychotic
ECT if severe
organic cause of mania
brain tumour, CVA
new course of steroids
hyperthyroidism - (eg. elderly forgotten to take antithyroid drugs)
drugs eg cocaine
late onset schizophrenia RFs and treatment
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
Alcohol missuse risks
withdrawal- seizures and delerium tremens
alcohol related dementia
wernick-Korsakoff syndrome
reduced life expectancy
30% alcohol related admissions
Differentiate between wernikes and korsakoffs
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
