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Pyschiatry > Old age psychiatry > Flashcards

Old age psychiatry Flashcards

1
Q

What is delirium

A

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

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2
Q

Who is affected by delirium

A

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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3
Q

Delirium aetiology

A

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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4
Q

Deliriogenic drugs

A

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

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5
Q

What is a low output state

A

MI, ARDS, PE, CHF, COPD

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6
Q

Metabolic disorders causing delirium

A

Electrolyte imbalance, thyroid disorders, Wernicke’s

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7
Q

Delirium presentation types

A

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

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8
Q

Global presentation of delirium

A

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

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9
Q

Delirium can present with sundowning which is…

A

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

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10
Q

Delirium bedside approach

A
  • 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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11
Q

Delirium bloods approach

A
  • FBC - infection
  • U&E - electrolyte disturbance or dehydration
  • TFT
  • BM
  • Blood cultures
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12
Q

Delirium imaging approach

A
  • CXR
  • AUS
  • Neuroimaging reserved if cause still not established and it could be heard injury/vascular
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13
Q

Delirium management principles

A

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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14
Q

Pharmacological management of delirium

A

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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15
Q

What is dementia

A

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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16
Q

How does dementia often begin

A

Typically starts with memory - forgetfulness

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17
Q

How does dementia affect memory

A

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

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18
Q

How does dementia affect language

A

Receptive and expressive dysphasia

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19
Q

How does dementia affect subcortex

A

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

20
Q

How does dementia affect mood

A

Depression and anxiety may coexist

21
Q

What are BPSD

A

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

22
Q

What are the behavioural symptoms of dementia

A
  • Restlessness, wandering
  • Disturbed sleep/wake reversal
  • Shouting/inappropriate behaviour
  • Disinhibition
  • Aggression
23
Q

What are the psychological symptoms of dementia

A
  • Delusions
  • Hallucinations
  • Depression/anxiety
24
Q

What is important in dementia risk assessment

A
  • Risk to self from self neglect, getting lost
  • Risk from others financially or neglect/abuse
  • Risk to others with disinhibited or aggression, dangerous driving
25
Q

AD risk factors

A
  • Age
  • Female
  • Low IQ
  • Head injury
  • Previous depression
  • Genetic (both early and late onset)
26
Q

AD pathology

A
  • Beta amyloid plaques
  • Phosphorylation of tau causes neurofibrillary tangles
  • Subsequent cholinergic neuronal loss and cortical atrophy
27
Q

AD onset

A

Insidious onset with gradual decline

28
Q

AD features

A

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

29
Q

AD imaging

A

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

30
Q

VD risk factors

A

Age
Male
CVD risk factors

31
Q

VD pathology

A

Multiple cortical infracts from arteriosclerosis

32
Q

VD onset

A

Sudden onset with stepwise decline coinciding with CV events.

33
Q

VD features

A

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

34
Q

VD imaging

A

Multiple white matter lucencies, atrophy

35
Q

DLB risk factors

A

Age
Male
Genetic

36
Q

DLB pathology

A

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

37
Q

DLB onset

A

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

38
Q

DLB features

A
  • Fluctuating cognition
  • Visual hallucinations (small people/animals)
  • Parkinsonism
  • Autonomic dysfunction (syncope)
  • REM sleep disorder
39
Q

DLB imaging

A

Atrophy

40
Q

Dementia bedside investigation

A
  • Cognitive testing
  • Collateral history
  • Physical examination and observations
41
Q

Dementia bloods

A
  • FBC
  • U&Es
  • B12
  • Folate
  • Bone profile
  • Lipid profile
42
Q

Dementia imaging

A

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

43
Q

Psychological management of dementia

A
  • Psychoeducation and counselling for accepting diagnosis
  • Reminiscence therapy
  • Cognitive stimulation therapy
  • Validation therapy
  • Multisensory therapy
  • ABC charts for behavioural approach
44
Q

Social management of dementia

A

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

45
Q

Biological management of AD

A
  • 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
46
Q

Biological management of VD

A

Optimise CV health

47
Q

Biological management of DLB

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

Pyschiatry (6 decks)

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