Old Age Psychiatry

Question 1

Psychosis in Old-Age (history)

Answer 1

Clarify HPC (onset, duration)
Explore auditory hallucinations (quality, content, number, 2nd/3rd person, commentary, commands, insight)
Hallucinations in other modalities
Delusional beliefs
Thought interference and passivity phenomena
Mood (mood, sleep, appetite, enjoyment)
Memory
Alcohol and drugs
Risk
Physical health (inc vision/hearing) and medications

Question 2

Psychosis in Old-Age (explanation)

Answer 2

Clarify diagnosis
Explain causes (family history, personality traits, hearing impairment)
Explain treatment (inpatient/outpatient, MHA)
Explain medication (mechanism, side-effects, duration 6m)
Alternative treatments (CBT)
Long-term management (CPN, OT/PT, discharge location)

Question 3

Stress/distress symptoms in dementia (history)

Answer 3

Clarify HPC (duration, triggers, aggression)
Psychiatric symptoms (diagnosis, follow-up, medications, mood, psychotic Sx)
Physical symptoms (medical history, temperature, falls, pain, elimination)
Environmental changes (space, people, activities)

Question 4

Stress/distress symptoms in dementia (explanation)

Answer 4

Clarify concerns
Explain treatment rationale (symptoms, risk, failed management)
Explain side-effects (inc stroke risk, risk/benefit, low dose, duration)
Alternative treatments (orientation, reminiscent therapy, art therapy, pet therapy, doll therapy, activities, family involvement)
Questions

Question 5

Risk factors for paraphrenia

Answer 5

Female
Hearing/visual impairment
Single, no children
CVAs
Social isolation

Question 6

Side-effects of acetylcholinesterase inhibitors

Answer 6

GI upset, incontinence, loss of appetite, dizziness, drowsiness, bradycardia
CI in asthma/COPD (except rivastigmine)

Question 7

Side-effects of memantine

Answer 7

Constipation, headache, dizziness, drowsiness, high blood pressure

Question 8

Alzheimer’s genetics

Answer 8

Parents - 3-4x higher risk

Familial dementia - more likely early onset

Question 9

Risk factors for Alzheimer’s disease

Answer 9

History of diabetes
Repeated head injury
History of depression
Vascular risk factors (HTN, stroke, cholesterol)
Increasing age
Family history of dementia
Low educational attainment

Question 10

Dementia (history)

Answer 10

Clarify HPC (onset, duration)
Explore memory difficulties (short-term, long-term)
Orientation (day/dates, confused, recognizing people)
Communication (word-finding, understanding, identify objects)
Functioning (dressing, washing, toileting, walking, money, shopping, food, transportation)
PMHx and risk factors (head injury, low mood)
Risk (wandering, getting lost, fire, flooding, exploitation, abuse, aggression, self-injury).

Question 11

Dementia (medication)

Answer 11

Clarify understanding
Donepezil, rivastigmine, galantamine
Purpose and mechanism (increase ACh, slow down progression, improve QoL)
Duration and efficacy (40-50% respond, memory monitoring, 6m reviews)
Side-effects/CIs (dizziness, drowsiness, low of appetite, bradycardia, GI upset, incontinence)
Address other concerns and offer leaflets

Question 12

Vascular dementia (explanation)

Answer 12

Clarify diagnosis and aetiology
Progression and prognosis (mean survival 3 years)
Explain medication (AChIs not indicated, control RFs, treat depression etc)
Alternative treatment (lifestyle modification)
Address other concerns and offer leaflets

Question 13

Lewy Body Dementia (explanation)

Answer 13

Clarify diagnosis and aetiology (LBs affect chemicals)
Common symptoms (falls, fluctuating cognition and hallucinations)
Difference between LBD/PDD (1 year between Sx for PDD)
Explain medication options (avoid antipsychotics, rivastigmine, PD meds - neurology)
Alternative treatment (PT/OT)
Address other concerns and offer leaflets

Question 14

Lewy Body Dementia (behaviour management)

Answer 14

Clarify HPC (onset, duration)
Clarify possible causes (medication change, illness)
Explain medication options (increase current meds, add antipsychotic)
Alternative treatment (re-orientation, MDT involvement, light therapy/sleep hygiene)
Address other concerns

Question 15

Fronto-temporal dementia (history)

Answer 15

Clarify HPC (onset, duration)
Explore memory difficulties (short-term, long-term)
Orientation (day/dates, confused, recognizing people)
Communication (word-finding, understanding, identify objects)
Explore frontal lobe Sx (personality, sexual inappropriateness, plans, mood, impulsivity, repetitiveness)
Functioning (dressing, washing, toileting, walking, money, shopping, food, transportation)
Risk (wandering, getting lost, fire, flooding, exploitation, abuse, aggression, self-injury).
PMHx and risk factors (head injury, low mood)

Question 16

MMSE cognitive examination

Answer 16

ORARLP
Orientation -
Year, Season, Date, Day, Month
Where are we now? Country, County, Town, Hospital, Floor?
Registration -
name 3 apple, table, key
Attention - Spell WORLD backwords.
Recall - tell me those three words?
Language (NIPES) -
N: Name two objects (e.g pen, watch).
I: No if’s ands or buts - repeat
P: 3 Stage command - place indext finger of right hand on your nose and then left ear.
E: Read and obey - Close your eye
Pentagons: copy this picture - intersecting pentagons.

Question 17

Mild Cognitive Impairment (explanation)

Answer 17

• Can be thought of in between normal thinking and dementia
• Score indicates cognition affect
• Some impairment in memory but no impact on functioning.
• 5-15% of MCI at an increase risk of dementia.
• Managment: No meds, promoting health e.g. diet, exercise. Correcting sensory issues. Increase social network. Increased monitoring - invited back for r/v 6-12 months

Question 18

Delirium (history)

Answer 18

Clarify timecourse and or fluctuations including sundowning.
New medications?
S+S of infection?
Constipation?
Passing urine?
Trauma?
CVA?
Electrolyte disturbance?
?Attention affected
Sleep wake cycle?
Behaviour?

Question 19

Delirium (management)

Answer 19

Bio: treat root cause of delerium - ie. infection/withdraw causing medication/laxatives/catheter etc.
Lorazepam or haloperidol if required WITH caution, low dose, review. Risk falls
Psycho: Talking with nursing - 1:1 to support with falls/oreintetion
Social: Side room with natural light, clock, hearing aids/glasses etc.

Question 20

Indications for CT head in delirium

Answer 20

Falls, headinjury, focal neurology, stroke,
Indicated in confusion screen.

Question 21

Mania in elderly patient (history)

Answer 21

DDx: FTD, hyperthyroid, ?steroid course, delerium, substance misuse, BPAD.

Heavier influence is ruling out common pathologies in elderly vs Adult.

Risk: sexual disinhibition, financial exploitation, aggression.

Bloods, cognitive assessment, CT head, Urine dip + MSU, CXR

Question 22

Mania in elderly patient (explanation)

Answer 22

Mania is a condition that is associated with elevated or extreme changes in mood, with increased energy level, risk taking (sexual disinhibiton, overspending, lack of sleep, neglect).
Over thinking, rapid speech.
Can be accompanied with psychosis including delusions, hallucinations.
Lasts at least a week.

Hypomania - milder form, can last for less time.

Discuss and explain why not differentials.
Discuss and explain further investigations.
Lithium still used - less frequently due to risks if
patient has CKD.
Otherwise mood stabiliser if indicated.
More mixed depressive/manic states.
More likely secondary mania.
Can be associated with increased psychotic features and hospitalisation.

Question 23

Frontal Lobe Assessment

Answer 23

PAVL Go Key Reflex
P: Personality and smell - ?any changes, has anyone else noticed?
A: Abstraction -
Proverb interpretation: Too many cooks spoil the broth?
A stitch in time saves nine?
Cognitives: How many Camels in Denmark? How high is a double decker bus?
Similarities: Train & Bicycle, Watch & Ruler.
V: Verbal Fluency - Letter fluency - name as many animals in one minute.
L: Luria - Fist Edge Palm - 5 x for normal.
Go-no-go Test: First: When I tap once, you tap twice, when I tap twice you tap once.
Second: When I tap once, you tap once.
When I tap twice, you do not .
Reflexes: Graps (stroke palm), pout when stick to lips, Palmomental (stroking thenar eminence -> contraction of mentalis muscle).

Question 24

Pariental Lobe Assessment

Answer 24

Dominant:
Receptive dysphasia (should be obvious)
Acalculia - 4+7
Agraphia - Write a sentence
R-L disorientation - Touch R ear with L hand
Finger agnosia: show me your R index finger
Ideomotor apraxia: Brushing hair
Astereognoia: Close eyes, object (pen/coin) in palm, ask them to tell you.
Agraphagnosia: Eyes closed - trace H on palm tell me what letter.

Non-dominant:
Topographical disorientation - Ask if confused lost new places.
Constructional apraxia: Intersecting pentagons.
Anosagnoia: ask patient if they have deficit
Neglect: Wiggle R then L then both fingers - which is wiggling.

Question 25

Temporal Lobe Assessment

Answer 25

Dominant:
Language:
Receptive aphasia - repeat words.
Verbal retention: Harry Barnes, 73 Orchard Close, Kingsbridge, Devon. Ask to repeat.
Alexia: Read a couple of sentences
Agraphia: Write a couple of sentences
Anomia: Objects in room, increasing order of difficulty: pen bottle watch nib.
Check retention.

Non-dominant:
Draw abstract shape - ask to copy
Hemisomatagnosia 0 are all 4 limbs working well?
Prosopagnoaia (any difficulty recognising faces or Benton facial).
Musical recognition?
Non verbal retention (repeat drawing).

Both:
Semantic memory (facts):
Current prime minister?
What happened to JFK?
Which City Eiffel Tower?
River that runs through London?

Autobiographical memory:
What did you have breakfast?
How did you get here?
Where were you born?
What was your first school?

Visual Fields (upper quadrantanopia).
Epilepsy: ?ever had
Psychosis: Strange beliefs/voices.