Old age psychiatry Flashcards by Pavan Khatkar

What is delirium

Acute and transient confusional state caused by underlying emotional or physical health disturbance.

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Who is affected by delirium

Medical inpatients, post-op patients and Icu admitted patients. Older age, male, poly pharmacy and underlying medical/physical conditions are all risk factors

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Delirium aetiology

DELIRIUMS:
- Drugs/alcohol
- Eyes, ears, emotional disturbance
- Low output state
- Ictal (seizure Hx)
- Retention: urinary or constipation
- Iatrogenic
- Under hydration or nutrition
- Metabolic
- Subdural haematoma/ sleep disturbance

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Deliriogenic drugs

Anti-cholinergics, sedatives, opiates, anti-convulsants, steroids

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What is a low output state

MI, ARDS, PE, CHF, COPD

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Metabolic disorders causing delirium

Electrolyte imbalance, thyroid disorders, Wernicke’s

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Delirium presentation types

Hypoactive (easy to miss)
Hyperactive
Mixed (most common)

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Global presentation of delirium

Sudden onset, altering consciousness and cognition (inattention, disorganised thoughts), mood changes, possibly some persecutory delusions or visual hallucinations.

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Delirium can present with sundowning which is…

Sundowning is agitation and confusion worsening in the late afternoon or evening.

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Delirium bedside approach

Full physical examination and observations
MSE + cognitive assessment
Check drug chart
?Collateral Hx
Urine MC&S - don’t do in over 65s due to low sensitivity

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Delirium bloods approach

FBC - infection
U&E - electrolyte disturbance or dehydration
TFT
BM
Blood cultures

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Delirium imaging approach

CXR
AUS
Neuroimaging reserved if cause still not established and it could be heard injury/vascular

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Delirium management principles

Treating the underlying cause. Non-pharmacological strategies should be the first line, which include:
- Providing an environment with good lighting
- Maintaining a regular sleep-wake cycle
- Regular orientation and reassurance
- Ensuring the patient’s glasses and hearing aids are used if needed

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Pharmacological management of delirium

Short course of small doses of haloperidol or lorazepam. Possibly olanzapine but caution side effects in elderly - only use pharmacological therapy if pt is v. agitated

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What is dementia

An acquired chronic usually progressive decline in cognitive function that interferes with ADLs - need to be present for at least 6 months to distinguish from delirium

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How does dementia often begin

Typically starts with memory - forgetfulness

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How does dementia affect memory

Forgetfulness –> anterograde amnesia –> retrograde amnesia –> disoriented to time –> person –> place.

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How does dementia affect language

Receptive and expressive dysphasia

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How does dementia affect subcortex

Deep brain structural damage can cause bradyphrenia (mental slowness), bradykinesia, depression, executive dysfunction

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How does dementia affect mood

Depression and anxiety may coexist

What are BPSD

Behavioural and psychological symptoms of dementia - typically late onset and can cause risk

What are the behavioural symptoms of dementia

Restlessness, wandering
Disturbed sleep/wake reversal
Shouting/inappropriate behaviour
Disinhibition
Aggression

What are the psychological symptoms of dementia

Delusions
Hallucinations
Depression/anxiety

What is important in dementia risk assessment

Risk to self from self neglect, getting lost
Risk from others financially or neglect/abuse
Risk to others with disinhibited or aggression, dangerous driving

AD risk factors

- Age - Female - Low IQ - Head injury - Previous depression - Genetic (both early and late onset)

AD pathology

- Beta amyloid plaques - Phosphorylation of tau causes neurofibrillary tangles - Subsequent cholinergic neuronal loss and cortical atrophy

AD onset

Insidious onset with gradual decline

AD features

Starts with spatial navigation problems e.g. getting lost. 4As: - Amnesia - Aphasia - Agnosia - Apraxia

AD imaging

Cortical atrophy, especially in medial temporal and parietal lobes. Enlarged sulci and ventricles

VD risk factors

Age Male CVD risk factors

VD pathology

Multiple cortical infracts from arteriosclerosis

VD onset

Sudden onset with stepwise decline coinciding with CV events.

VD features

Patchy cognitive impairment - symptoms reflect the site of lesions. - Visual disturbance - Sensory or motor symptoms - Difficulty with attention and concentration - Seizures - Memory disturbance - Gait/speech/emotional disturbance

VD imaging

Multiple white matter lucencies, atrophy

DLB risk factors

Age Male Genetic

DLB pathology

Lewy body formation in cingulate gyrus and neocortex due to difficulty metabolising a-synuclein protein

DLB onset

Cognitive impairment typically precedes movement disorder but they always occur within a year of each other's onset. Fluctuating symptoms

DLB features

- Fluctuating cognition - Visual hallucinations (small people/animals) - Parkinsonism - Autonomic dysfunction (syncope) - REM sleep disorder

DLB imaging

Atrophy

Dementia bedside investigation

- Cognitive testing - Collateral history - Physical examination and observations

Dementia bloods

- FBC - U&Es - B12 - Folate - Bone profile - Lipid profile

Dementia imaging

If diagnosis is not clear - MRI for early diagnosis, better for detecting subcortical vascular changes - SPECT or PET scan if DLB suspected

Psychological management of dementia

- Psychoeducation and counselling for accepting diagnosis - Reminiscence therapy - Cognitive stimulation therapy - Validation therapy - Multisensory therapy - ABC charts for behavioural approach

Social management of dementia

MHOA (mental health for older adults) team: - Planning: advanced decision, LPA, driving - Home support liaising with OT - keep them at home for as long as possibly - Care home coordination when they can't live at home anymore

Biological management of AD

- AChE inhibitors: donepezil, rivastigmine, galantamine = first line in mild-moderate AD - 2nd line = NMDA inhibitor: memantine (NB - first line in severe AD) - BPSD - low dose risperidone may be used

Biological management of VD

Optimise CV health

Biological management of DLB

- AChEI for mild-moderate DLB - Clonazepam for REM sleep disturbance - Don't use antipsychotics due to Parkinsonism risk

With dementia there is no ‘1st line’ drug, though [_] are a LAST Line and are associated with increased stroke and VTE in the elderly, and are contraindicated in LBD and PD.

Antipsychotics

Dementia risk assessment: HOW SAFE

- HOme safety (gas) - Wandering - Self neglect - Abuse - Falls - Eating