Old Age Psychiatry Flashcards
What are the outcomes of older adults (over 70) with co-morbid mental health problems after an acute hospital admission?
27% do not return to own home
After 180 days 31% died and 42% readmitted
What is the ABCD of dementia?
A - activities of daily living
B - behavioural and psychiatric symptoms of dementia
C - cognitive impairment
D - decline
Describe dementia
6 month duration and usually progressive
Diagnosis based on history
Cognitive testing with emphasis on relevant lobes
What are the cognitive features of dementia?
Memory - dysmnesia
Plus one or more of dysphasia, dyspraxia, dysgnosia (not recognising objects) and dysexecutive functioning
Describe fitness to drive and dementia
Notify DVLA at diagnosis
If early diagnosis then license may be yearly
What imaging is used in dementia?
CT, CT/ SPECT, DAT scan and MRI
How is AD diagnosed in primary care?
Symptoms suggesting cognitive impairment - clinical history, MMSE, physical and bloods - exclude delirium and depression - confirm with specialist referral
What is the aetiology of dementia?
Frontotemporal
Alcohol and ARBD
Subcortical - Parkinson’s, Huntington’s and HIV
Prion protein - CJD
What are the reversible causes of dementia?
Delirium, normal pressure hydrocephalus, subdural haemorrhage, tumours, vitamin B12 deficiency, hypothyroidism, hypercalcaemia, alcohol misuse and drugs
Describe the course of dementia
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
Describe Alzheimer’s disease
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
Describe vascular dementia
Unequal distribution of deficits
Focal impairments and evidence of cerebrovascular disease
Step wise decline with sudden changes
Small vessel disease can give gradual decline
What are the key features of lewy body dementia?
Visual hallucination, fluctuations and Parkinsonism
What are the supportive features of lewy body dementia?
Sensitivity to antipsychotics, reduced uptake on SPECT or PET scan, increased falls and REM sleep disorder
What questionnaire is used in lewy body dementia?
DIAMOND
How does dementia with lewy bodies look on a DAT scan?
Re-uptake of dopamine transporter in the putamen is reduced - leads to full stop sign
Describe frontotemporal dementia (Pick’s disease)
Behavioural disorder - personality changes
Can be early onset and early emotional blunting
Speech disorder
Frontal dysexecutive syndrome
Neuroimaging - abnormalities in frontotemporal lobes
What are the behavioural and psychological symptoms seen in dementia?
Agitation, psychosis, affective (depression, anxiety, lability, hypomania and apathy), disinhibition and behaviour in eating, toilet, dressing and sleep wake cycle
What is the drug treatment of dementia?
Acetylcholinesterase inhibitors and Memantine for mild to moderate to severe AD
Antipsychotics, antidepressants, anxiolytics, hypnotics and anticonvulsants
What are the acetylcholinesterase inhibitors used in dementia?
Donepezil, galantamine and rivastigmine
Improved cognitive function and behaviour
Delay time to institutionalisation
What are the risks of acetylcholinesterase inhibitors?
Nausea, vomiting, diarrhoea, fatigue, insomnia, muscle cramps, headaches, dizziness, syncope and breathing problems
Describe anti-amyloids antibodies?
Lecanemab, aducanumab and gantenerumab
Possibly clearing amyloid from brains - slow burn disease
Lecanemab is first line for any type of dementia
How long is lacenemab given for?
Trial only 18 months
Amyloid testing needed
Changing to brain structure and swelling seen on MRI
Long infusions every 2 weeks
What is the guidance on anti-psychotic use?
Not first line except when extreme risk
Address treatable causes
High rate of spontaneous recovery
Lowest dose of atypical for shortest time
What does capacity mean?
Ability to understand the information relevant to a decision or action, and to appreciate the reasonable foreseeable consequences of not taking action or decision
What are 5 points to consider in capacity?
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
What are the 6 Cs of capacity?
Capacity, consent, compliance, coercion, certification and common sense
What are normal symptoms of grief, mourning and bereavement?
Alarm, numbness, pining, depression and recovery + organisation
What are the abnormal symptoms of grief, mourning and bereavement?
Persisted beyond 2 months, guilt, thoughts of death, worthlessness, psychomotor retardation, prolonged functional impairment and psychosis
