Old Age Psychiatry Flashcards
ABCD of Dementia
A for Activities of Daily Living (ADLs)
B for Behavioural and Psychiatric Symptoms of Dementia (BPSD)
C for Cognitive Impairment
D for Decline
diagnosing dementia
6 months duration, usually progressive
Diagnosis based on Hx and collateral
PMHx & Medication (particularly anti cholinergics)
Cognitive testing with emphasis on relevant lobes
Neuropsychology
Physical examination & bloods
Supportive evidence from brain imaging
Diagnosis deferred in delirium
Cognitive features of Dementia
Memory (dysmnesia)
Plus one or more of
dysphasia (communication)
expressive
receptive
dyspraxia (inability to carry out motor skills)
dysgnosia (not recognising objects)
dysexecutive functioning (initiation, inhibition, set-shifting, abstraction)
what should the DVLA be informed about if a patient has dementia
Dementia or Organic Brain Syndrome
notify DVLA at diagnosis
if early dementia license may be yearly
“those with poor short term memory, disorientation or lack of insight should almost certainly not drive”
what screening tests should be done for dementia bedside
MMSE
Allen cognitive level screen
what are different types of dementia
alziemers
vascular
mixed
lewy body dementia
frontotemporal dementia
parkinson’s dementia
aetiology of dementia non reversible causes
Frontotemporal (Picks) (behavioural, PNFA: progressive non fluent aphasia, semantic)
Alcohol, ARBD (alcohol dementia/ Korsakoffs (thiamine deficiency))
Subcortical - Parkinson’s, Huntington’s, HIV
Prion Protein eg CJD
what are some reversible causes of dementia
Delirium
Normal pressure hydrocephalus
Subdural haemorrhage
Tumours
Vitamin B12 deficiency
Hypothyroidism
Hypercalcaemia
Alcohol misuse
Neurosyphilis
Drugs
Anticholinergics
what are main features of Alzheimer’s disease
Early impairment of memory and executive function
Gradual progression with often unclear onset
Main features:
Amyloid plaques & tau tangles
Atrophy following neuron death
Reduction in Acetylcholine
Different types of dementia have different blood flow patterns, which can be used to help diagnose the condition.
through which imaging?
SPECT comparison
key features of vascular dementia
Unequal distribution of deficits
Evidence of focal impairments on neuro exam
Evidence of cerebrovascular disease - PMHx
Step wise decline with sudden changes
Small vessel disease can give gradual decline
key features lewy body dementia
Visual hallucinations
Fluctuations
Parkinsonism
what are supportive of the diagnosis
Sensitivity to antipsychotics
Reduced dopamine uptake on SPECT or PET scan
Increased falls
REM sleep disorder
diagnostic scans for Lewy body dementia
diamond-lewy
DATscan
what are the features of frontotemporal dementia
Behavioural disorder – personality change
Can be early onset
Early emotional blunting
Speech disorder - altered output, stereotypy, echolalia, perseveration, mutism
diagnostic tests for frontotemporal dementia
Neuropsychology - frontal dysexecutive syndrome. Memory, praxis and visuospatial function not severely impaired
Neuroimaging - abnormalities in frontotemporal lobes
Neurological signs commonly absent early; parkinsonism later; MND in a few; autonomic; incontinence; primitive reflexes
Behavioural and Psychological Symptoms in Dementia
Agitation (Restlessness, Wandering)
Psychosis (Delusions, Hallucinations)
Affective (Depression, Anxiety, Lability, Hypomania, Apathy)
Disinhibition (Aggression, Sexual)
Behaviour (Eating, toileting, dressing, Sleep-wake cycle)
drug treatment for dementia
Acetylcholinesterase Inhibitors (AChI) for mild to moderate AD
donepezil, rivastigmine, galantamine
Memantine (glutamate receptor antagonist) for moderate to severe AD
Antipsychotics (eg. risperidone, quetiapine, amisulpride)
Antidepressants (eg. mirtazapine, sertraline)
Anxiolytics (eg. lorazepam)
Hypnotics (eg. zolpidem, zopiclone, clonazepam)
Anticonvulsants (eg. valproate, carbamazepine)
Acetylcholinesterase Inhibitors
Donepezil, Galantamine, Rivastigmine
Similar clinical effects on MMSE & ADAS COG
10 RCTs showed improved cog function, ADLs & behaviour however small Rx effects
Delays time to institutionalisation
Risk vs benefit
Nausea, vomiting, diarrhoea
Fatigue, insomnia
Muscle cramps
Headaches, dizziness
Syncope
Breathing problems
Mabs (monoclonal antibody) in treatment of dementia
Lecanemab, Aducanumab and Donanemab (anti-amyloid antibodies)
Possibly clearing amyloid from brains →slow down disease → longer independence and milder symptoms.
Lecanemab 1st treatment for any type of dementia to reverse physical changes and slow decline in memory and thinking.
Guidance on Anti Psychotic use in dementia
Not first line except where extreme risk
Detailed assessment of BPSD including ABC
Address treatable causes
Symptoms primarily a problem for patient or carers
High rate of spontaneous recovery
Psychological approaches including structured activity
Discussion regarding best interests
Lowest dose of atypical for shortest time (ideally<12 weeks)
Monthly review recommended
Non pharmalogical use in dementia
Other causes of distress
ABC approach
Communication
With patient and family
Any form of Distraction
capacity definition
ability to understand information relevant to a decision or action, and to appreciate the reasonably foreseeable consequences of not taking action or decision
5 points to consider when thinking about capacity
1) Does the patient UNDERSTAND the information?
2) Does the patient RETAIN the information long enough to make a decision?
3) Can the patient COMMUNICATE the decision?
4) Can the patient WEIGH UP the information in order to make a decision?
5) Does the patient BELIEVE the information they are given?
1) A patient is deemed to have capacity unless proven otherwise
2) A patient should be supported to make a decision
3) A person can not be deemed to incapable if their decision is eccentric or unwise
4) Anything done for the patient must be in their best interest
5) Always use the least restrictive option
6) Capacity should be assessed on the topic of question
7) Patient’s should be assessed at their ‘peak time’
8) Speak to family to get historic views? Advanced statement
what are the 6 C’s of capacity
Capacity
Consent
Compliance
Coercion
Certification
Common sense
what is a power of attorney
Finance
Usually easier to retain capacity re granting this than for welfare
Welfare
Big issues re powers to have you reside
Are the powers even being used?
Does it have to be ‘activated’
Common sense i.e. ‘best interests’
letter
Are the powers being misused?
Who has the powers?
Who doesn’t have the powers?
Revocation of power of attorney
Public Guardian’s Office
what is guardianship
Finance
Welfare
They lack capacity to grant POA
Two medical certificates
GP
Psychiatrist
Detailed report from MHO (social worker)
Will take into account family and those nominated in the application
Is it needed?
Is it agreed?
Who will be the guardian?
how do you establish normal versus abnormal greif and mourning
Normal
Alarm
Numbness
Pining – illusions or hallucinations may occur
Depression
Recovery and reorganisation
Abnormal
Persisted beyond 2 months
Guilt
Thoughts of death
Worthlessness
Psychomotor retardation
Prolonged and marked functional impairment
Psychosis
suicide in the elderly
Same rate as for under 25 age group
Half the rate of other age groups
Males more than females
Most are depressed
DSH is rare in the elderly
loneliness
widowed
ill health
chronic pain
recent life events
few seeing psychiatrist
