Old Age Psychiatry Flashcards
Which anti-depressants are most likely to contribute to delirium?
Tricyclics - especially tertiary amine anti-depressants
Other notable medications include benzodiazepines (typically longer acting i.e. diazepam), opioids and anti-cholinergic medications
Outline the use of different cognitive drugs for dementia?
For Alzheimers:
- Donepezil, Rivastigmine & Galantamine –> mild to moderate Alzheimers
- Memantine –> for moderate if unable to tolerate the above agents/contraindicated or add in for severe
For Dementia with Lewy Bodies:
- AchE-I (Rivastigmine or Donepezil) for mild - severe
- Galantamine if above not tolerated
- Memantine if AchE-I not tolerated/contraindicated
Only consider AchE-I or memantine for vascular dementia if Alzheimer’s, Parkinson’s or DLB present too
Do not offer AchE-I for frontotemporal dementia
Do not offer AchE-I for cognitive impairment due to multiple sclerosis
Outline the severity of dementia according to MMSE
Mild: 21 - 26
Moderate: 10 - 20
Severe: < 10
When is aspirin indicated in vascular dementia?
Only with established vascular disease - recent Cochrane review of RCTs showed that aspirin does not prevent vascular dementia in same way as it does in strokes, PVD and MI
Outline the mechanisms of Acetylcholine-esterase inhibitors?
Donepezil - selective and reversible –> metabolised through CYP2D6 and CYP3A4 (minor)
Rivastigmine - non-competitive and reversible (also works by inhibiting butlycholine-esterase) – > little involvement of CYP enzymes
Galantamine - competitive and reversible (also a nicotinic receptor antagonist) –> metabolised through CYP2D6 and CYP3A4
n.b memantine antagonises NMDA receptors (also 5HT3 antagonist) –> memantine is primarily metabolised by the kidneys
Name some risk factors for Charles Bonnet syndrome?
Advancing age
Social isolation
Visual impairment
Early cognitive impairment
Sensory deprivation
Outline the ICD-11 diagnosis for dementia?
Marked impairment in two or more cognitive domains relative to the expected level for their age and pre-morbid functioning
n.b commonly involves impairment of memory however it is not only this and other domains such as executive functioning, attention, language, psychomotor speed, visuoperceptual and visuospatial capabilities may be affected
Requires:
- Information from the informant, individual or clinical observation
- Substantial impairment in memory performance as demonstrated by neuropsychological testing
The symptoms result in impairment in personal, social or occupational functioning
The symptoms are not better accounted by disturbance of consciousness or altered mental state
What scale may be used to assess for depression in dementia?
Cornell scale - 30 minutes and involves and interview with the caregiver and the patient (not self-report)
How does the mneumonic DEMENTIA help to screen for reversible causes of dementia?
Drugs
Emotions (depressed)
Metabolic (hyper/hypothyroidism, hyper/hypoparathyroidism, Cushing’s,
Addison’s, Wilson’s disease, Hashimoto’s encephalitis)
Eyes or ears decline
Normal pressure hydrocephalus
Tumour
Infection (Syphillis,
Whipple’s disease,
sarcoidosis, AIDs, meningitis)
Anaemia (B12/Folate)
What is the first line agent recommended by NICE for use in delirium?
Haloperidol
- note Maudsley guidelines recommend lorazepam if alcohol/hypnotic withdrawal otherwise to avoid as can worsen
Other agents not recommended by Maudsley are:
- Donepezil
- Rivastigmine
- Trazodone
- Sodium valproate
Outline the clinical features of normal pressure hydrocepalus?
- Symmetrical broad based and mild high stepping gait
- Urinary incontinence (late sign) - before this there may be urge, frequency and incontinence
- Cognitive decline - slowness of mental processes and motor function (as it is a subcortical dementia there is difficulties in sustaining attention, switching attention and planning)
What are the causes of NPH?
50% identified cause with mechanical blockage - infection, trauma, subarachnoid haemorrhage
50% idiopathic
Name some investigations for NPH?
CT scan - increase in lateral ventricle size
CSF tap - withdraw 40-50ml then assess gait afterwards (low sensitivity and low predictive value)
What is the treatment of normal pressure hydrocephalus?
Ventriculo-peritoneal shunt
Name some features of chronic subdural haematoma?
Headache
Drowsiness
Altered GCS
Confusion
- fluctuating picture similar to subcortical dementia
- CT may be -ve in first 3-4 weeks
- Treatment is neuro-surgery with burr hole or steroids (dexamethasone)
–> risk of surgery is re-bleeding and seizures
What is the risk of getting Alzheimer’s in a first degree relative of a proband?
15 - 19%
Name some risk factors for the development of Alzheimer’s disease?
Protective:
- Apolipoprotein E2 allele
- NSAIDs
- Higher pre-morbid intelligence
- Oestrogen
Risk factors:
- Down’s syndrome
- Decline in
- Genetics:
–> Apolipoprotein E4 allele (chromosome 19) - one copy increases risk by 3 x // two copy increases risk by 8 x
–> Presenilin 2 (chromosome 1) - associated with early onset
–> Presenillin 1 gene (chromosome 14) - associated with early onset
–> beta-APP gene (chromosome 21)
Name some neuroimaging findings seen in Alzheimer’s
CT - cortical atrophy particularly over parietal and temporal lobes, dilatation of the 3rd ventricles which correlates with cognitive impairment
MRI: Reduced grey matter, hippocampus, Amygdala and temporal lobe volumes
SPECT: Characteristic reduction in blood flow in temporal and parietal regions (SPECT could
distinguish specific features of dementia of Alzheimer type at early stages and frontal lobe
dementia)
PET: Reduced blood flow and metabolism in temporal and parietal regions
MRS: Abnormal synthesis of membrane phospholipids early in the disease
Amyloid PET imaging – shows deposition of beta amyloid even in preclinical stages of dementia
What language difficulties may be present in Alzheimer’s?
Expressive and receptive aphasia
Lexical anomia - word finding difficulty
Outline some symptoms of Alzheimer’s?
Apraxia - inability to perform coordinated motor tasks
Impaired executive function
Impaired visuospatial abilities
Amnesia - initially short term memory before long term events (disorientation particularly time)
Agnosia - inability to recognise peripheral sensory information, parts of the body or people
Which AchE-I is preferred in Parkinson’s dementia or Alzheimer’s with Parkinson’s disease?
Rivastigmine
How long is Donepezil’s half life?
70hrs - this means it can be taken as once daily dosing
When may AchE-I be contraindicate?
Severe cardiac conduction difficulties or severe asthma
Why is memantine termed a disease modifying drug?
Because due to its non-competitive antagonism of PCP site of NMDA receptor it is meant to stabilise neurotoxic glutamatergic transmission
What alternative treatments have been talked about for Alzheimer’s?
Gingko biloba - Cochrane review found evidence unconvincing
Tacrine - rarely used due to risk of hepatotoxicity
Name some poor risk factors associated with Alzheimer’s disease?
Male
Onset < 65 years
Parietal lobe damage
Depression
Cognitive deficits such as apraxia
Absence of misidentification syndromes
Name 3 types of vascular dementia?
- Cognitive deficits following a single stroke (often with midbrain/thalamic infarcts)
- Multi-infarct dementia: stepwise deterioration and may be stability between episodes (minor infarcts)
- Progressive small vessel disease (Binswanger’s disease): multiple infarcts of small perforating vessels leads to lacunae formation (distinct infarcts) or leukoariasis
What is the Haschinki’s scoring system used for?
To try and identify likelihood of vascular dementia
- Scores > 7 means likely
- Scores < 4 unlikely
- Abrupt onset (2)
- Stepwise progression
- Fluctuating course (2)
- Normal confusion
- Relative preservation of personality
- Depression
- Somatic complaints
- Emotional incontinence
- History of hypertension
- History of strokes
- Evidence of associated
atherosclerosis - Focal neurological symptoms (2)
- Focal neurological signs (2)
- Unless marked, each item scores one
point. Score < 4 unlikely, scores > 7
likely to be vascular dementia
How does Biswanger’s present?
Biswanger’s disease - subcortical dementia: slowing of thought, slow intellectual decline, decreased short term memory, often gait disturbances and dysarthria. Aphasia and apraxia tend to only happen in complicated Biswanger’s
Is CADASIL autosomal dominant?
Yes
In Lewy Body Dementia where do Lewy Bodies tend to be found in the brain?
Brainstem
Subcortical Nuclei
Limbic Cortex (cingulate, enterohinal cortex, amygdala)
Neocortex (frontal, temporal, parietal)
What are the consensus criteria for the diagnosis of LBD?
Central - cognitive impairment sufficient to interfere with ADLs
Core features (two for probable, one for possible)
- Fluctuating cognition with profound variations in attention and alertness
- Well formed visual hallucinations that are recurrent
- Parkinsonism (seen in 70%)
Other supportive features:
- Repeated falls due to autonomic dysfunction
- Transient disturbances of consciousness
- Neuroleptic sensitivity (often worsens parkinson’s symptoms)
- Systematised delusions
- Hallucinations in other modalities
n.b short term memory may be relatively spared. Cognitive testing may reveal deficits in attention and visuospatial
What neuroimaging changes may be seen in LBD?
Relative sparing of medial temporal lobes
Enlargement of ventricles