Old age psychiatry Flashcards
What is delirium
Acute and transient confusional state caused by underlying emotional or physical health disturbance.
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
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
Deliriogenic drugs
Anti-cholinergics, sedatives, opiates, anti-convulsants, steroids
What is a low output state
MI, ARDS, PE, CHF, COPD
Metabolic disorders causing delirium
Electrolyte imbalance, thyroid disorders, Wernicke’s
Delirium presentation types
Hypoactive (easy to miss)
Hyperactive
Mixed (most common)
Global presentation of delirium
Sudden onset, altering consciousness and cognition (inattention, disorganised thoughts), mood changes, possibly some persecutory delusions or visual hallucinations.
Delirium can present with sundowning which is…
Sundowning is agitation and confusion worsening in the late afternoon or evening.
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
Delirium bloods approach
- FBC - infection
- U&E - electrolyte disturbance or dehydration
- TFT
- BM
- Blood cultures
Delirium imaging approach
- CXR
- AUS
- Neuroimaging reserved if cause still not established and it could be heard injury/vascular
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
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
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
How does dementia often begin
Typically starts with memory - forgetfulness
How does dementia affect memory
Forgetfulness –> anterograde amnesia –> retrograde amnesia –> disoriented to time –> person –> place.
How does dementia affect language
Receptive and expressive dysphasia
How does dementia affect subcortex
Deep brain structural damage can cause bradyphrenia (mental slowness), bradykinesia, depression, executive dysfunction
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
