Old Age Psychiatry

Question 1

What are the outcomes of older adults (over 70) with co-morbid mental health problems after an acute hospital admission?

Answer 1

27% do not return to own home
After 180 days 31% died and 42% readmitted

Question 2

What is the ABCD of dementia?

Answer 2

A - activities of daily living
B - behavioural and psychiatric symptoms of dementia
C - cognitive impairment
D - decline

Question 3

Describe dementia

Answer 3

6 month duration and usually progressive
Diagnosis based on history
Cognitive testing with emphasis on relevant lobes

Question 4

What are the cognitive features of dementia?

Answer 4

Memory - dysmnesia
Plus one or more of dysphasia, dyspraxia, dysgnosia (not recognising objects) and dysexecutive functioning

Question 5

Describe fitness to drive and dementia

Answer 5

Notify DVLA at diagnosis
If early diagnosis then license may be yearly

Question 6

What imaging is used in dementia?

Answer 6

CT, CT/ SPECT, DAT scan and MRI

Question 7

How is AD diagnosed in primary care?

Answer 7

Symptoms suggesting cognitive impairment - clinical history, MMSE, physical and bloods - exclude delirium and depression - confirm with specialist referral

Question 8

What is the aetiology of dementia?

Answer 8

Frontotemporal
Alcohol and ARBD
Subcortical - Parkinson’s, Huntington’s and HIV
Prion protein - CJD

Question 9

What are the reversible causes of dementia?

Answer 9

Delirium, normal pressure hydrocephalus, subdural haemorrhage, tumours, vitamin B12 deficiency, hypothyroidism, hypercalcaemia, alcohol misuse and drugs

Question 10

Describe the course of dementia

Answer 10

In the early stages - generally will be symptom free
As the illness progresses cognitive impairment becomes noticeable
Leads to functional decline and behavioural symptoms
Progressive condition

Question 11

Describe Alzheimer’s disease

Answer 11

Early impairment of memory and executive function
Gradual progression with often unclear onset
Amyloid plaques and tau tangles
Atrophy following neuron death and reduction in ACh

Question 12

Describe vascular dementia

Answer 12

Unequal distribution of deficits
Focal impairments and evidence of cerebrovascular disease
Step wise decline with sudden changes
Small vessel disease can give gradual decline

Question 13

What are the key features of lewy body dementia?

Answer 13

Visual hallucination, fluctuations and Parkinsonism

Question 14

What are the supportive features of lewy body dementia?

Answer 14

Sensitivity to antipsychotics, reduced uptake on SPECT or PET scan, increased falls and REM sleep disorder

Question 15

What questionnaire is used in lewy body dementia?

Answer 15

DIAMOND

Question 16

How does dementia with lewy bodies look on a DAT scan?

Answer 16

Re-uptake of dopamine transporter in the putamen is reduced - leads to full stop sign

Question 17

Describe frontotemporal dementia (Pick’s disease)

Answer 17

Behavioural disorder - personality changes
Can be early onset and early emotional blunting
Speech disorder
Frontal dysexecutive syndrome
Neuroimaging - abnormalities in frontotemporal lobes

Question 18

What are the behavioural and psychological symptoms seen in dementia?

Answer 18

Agitation, psychosis, affective (depression, anxiety, lability, hypomania and apathy), disinhibition and behaviour in eating, toilet, dressing and sleep wake cycle

Question 19

What is the drug treatment of dementia?

Answer 19

Acetylcholinesterase inhibitors and Memantine for mild to moderate to severe AD
Antipsychotics, antidepressants, anxiolytics, hypnotics and anticonvulsants

Question 20

What are the acetylcholinesterase inhibitors used in dementia?

Answer 20

Donepezil, galantamine and rivastigmine
Improved cognitive function and behaviour
Delay time to institutionalisation

Question 21

What are the risks of acetylcholinesterase inhibitors?

Answer 21

Nausea, vomiting, diarrhoea, fatigue, insomnia, muscle cramps, headaches, dizziness, syncope and breathing problems

Question 22

Describe anti-amyloids antibodies?

Answer 22

Lecanemab, aducanumab and gantenerumab
Possibly clearing amyloid from brains - slow burn disease
Lecanemab is first line for any type of dementia

Question 23

How long is lacenemab given for?

Answer 23

Trial only 18 months
Amyloid testing needed
Changing to brain structure and swelling seen on MRI
Long infusions every 2 weeks

Question 24

What is the guidance on anti-psychotic use?

Answer 24

Not first line except when extreme risk
Address treatable causes
High rate of spontaneous recovery
Lowest dose of atypical for shortest time

Question 25

What does capacity mean?

Answer 25

Ability to understand the information relevant to a decision or action, and to appreciate the reasonable foreseeable consequences of not taking action or decision

Question 26

What are 5 points to consider in capacity?

Answer 26

Does the patient understand the information
Does the patient retain the information
Can the patient communicate
Can the patient weigh up the information
Does the patient believe the information

Question 27

What are the 6 Cs of capacity?

Answer 27

Capacity, consent, compliance, coercion, certification and common sense

Question 28

What are normal symptoms of grief, mourning and bereavement?

Answer 28

Alarm, numbness, pining, depression and recovery + organisation

Question 29

What are the abnormal symptoms of grief, mourning and bereavement?

Answer 29

Persisted beyond 2 months, guilt, thoughts of death, worthlessness, psychomotor retardation, prolonged functional impairment and psychosis