Old Age Psychiatry Flashcards
Which of the following findings on a MRI scan would be most consistent with a
diagnosis of early Alzheimer’s disease?
A. Caudate atrophy
B. Cerebellar atrophy
C. Frontal atrophy
D. Hippocampal atrophy
E. Periventricular white matter lesions
D. Hippocampal atrophy
Loss of volume in the hippocampus (D) has been consistently demonstrated
in imaging studies in Alzheimer’s disease (AD). It is also reduced
relatively early in the progression of the disease. Specifically requesting
hippocampal volumes when investigating AD is important as otherwise it
may not be specifically reported. Other findings on neuroimaging include
generalized cerebral atrophy and enlarged ventricles. The caudate nucleus
(A) may be slightly smaller in AD but this would not be a particularly
important finding and may occur in other forms of dementia. It would
also be common in disorders such as Huntington’s disease. Cerebellar
atrophy (B) occurs late in AD, but is commonly seen in certain movement
disorders, including Wilson’s disease and Friedreich’s ataxia, among
others. Atrophy of the frontal lobes (C) may occur in AD, but it is usually a
later finding. Primary degeneration at this site is more consistent with one
of the frontotemporal dementias, such as Pick’s disease. Periventricular
white matter lesions (E) refer to lesions occurring in the non-cortical
areas adjoining the ventricles as opposed to subcortical lesions. In this
sense they usually refer to cerebrovascular lesions and are associated with
cognitive dysfunction (i.e. in vascular dementia).
Which of the following modes of action of currently available pharmacological
agents are thought to target some of the symptoms of dementia?
A. Drugs which decrease the levels of serotonin in the brain
B. Drugs which increase the levels of dopamine in the brain
C. Drugs which increase the levels of acetycholine in the
brain
D. Drugs which decrease the levels of histamine in the brain
E. Drugs which increase the levels of GABA in the brain
C. Drugs which increase the levels of acetycholine in the
brain
Compounds which increase the functional levels of acetylcholine (C)
in the brain appear to have some effect on cognition in dementia.
The compounds currently available block the enzyme that breaks
down acetylcholine in the synaptic cleft and are therefore termed
acetylcholinesterase inhibitors. In some patients (but by no means all)
they lead to improvements in activities of daily living, although they
have perhaps less direct benefit on memory itself. The drugs are not
curative.
A 79-year-old married woman comes to see her GP with her husband. The husband
reports his wife has a history of several months of deteriorating memory and is
now forgetting names and faces. He also explains that at times she seems much
more lucid, but there are occasions when she becomes very forgetful and confused,
sometimes saying there are people sat in the living room with them, which the
patient and her husband find distressing. More recently she has developed a tremor
in her left hand. What is the most likely diagnosis?
A. Alzheimer’s disease
B. Lewy body dementia
C. Parksinson’s dementia
D. Pick’s disease
E. Vascular dementia
B. Lewy body dementia
This is typical history of a patient suffering with Lewy body dementia/
dementia with Lewy bodies (DLB) (B). Lewy bodies are cytoplasmic
inclusions that are associated with numerous disorders, including
Parkinson’s disease. It accounts for around 5–10 per cent of all
dementias. There is a classic ‘triad’ of symptoms in DLB, consisting
of visual hallucinations, a fluctuating cognitive impairment and
parkinsonism. The fluctuations can be quite marked, with changes seen
from day to day or even hour to hour. In this way DLB is often confused
with delirium. The hallucinations are usually visual and complex.
They are often distressing to the patient, but by no means always. It
is not uncommon for patients to calmly state that other people are in
the room, for instance sat round the dinner table with them and their
spouse. Parkinsonism (which occurs within a year of onset of cognitive
difficulties) tends to consist of rigidity and gait difficulties more than
tremor. Patients also often have postural hypotension and a risk of
falls. DLB has classically been thought to have a more aggressive course
than Alzheimer’s, but this could in part be due to how it has been
treated in the past – it is now known that these patients have marked
and often fatal reactions to antipsychotic agents which are generally
contraindicated in patients with DLB.
Which of the following features would suggest a diagnosis of depression rather
than dementia in a patient presenting with memory loss?
A. Delusions
B. Fluctuating conscious level
C. Low mood
D. Poor verbal fluency
E. Excessive worry over memory loss
E. Excessive worry over memory loss
This question addresses the overlap between dementia and depression
and highlights how commonly the two are confused – wrongly
diagnosing someone with dementia can have disastrous consequences,
particularly if the patient is profoundly depressed. The term
‘pseudodementia’ is seldom used these days, and refers to depression
‘masquerading’ as dementia, although it does still have clinical
value it highlights the importance of distinguishing between the
two disorders. Depression in older age often presents with cognitive
difficulties. Subjective and excessive worrying by the patient over
their memory is not characteristic of dementia, and should prompt
a more thorough search for other depressive symptoms. Insight is
typically lost early in dementia (particularly Alzheimer’s disease),
with the majority of patients (although not all), having little insight
into or worry over what may be significant cognitive difficulties. In
depression, the patient may become extremely preoccupied with their
‘memory’; poor cognitive function in depression is often the result of
poor attention and concentration, and in-depth neuropsychological
tests which can control for this should reveal no significant memory
problems.
Which of the following statements most accurately reflects depression in older age?
A. Anxiety states are uncommon in depressive disorders in older age
B. Depression in older age is not associated with deliberate self-harm
C. Depression is less common in residential homes than in the general community
D. Old age is a risk factor for depression
E. Somatization is a common presentation of depression in old age
E. Somatization is a common presentation of depression in old age
Somatization (E), or the displacement of psychological distress such as
depression into physical complaints or symptoms, is common in the
depressed elderly. This may be a result of older people tending to minimize
their experience of sadness and that somatic complaints represent an
alternative way of expressing their distress. Also remember that ‘somatic’
complaints may actually also represent real undiagnosed medical problems.
Do not dismiss the depressed older person’s complaints of stomach pain at
the risk of missing an occult malignancy. Studies have shown that healthy
older people are no more at risk of becoming depressed than healthy
younger people (D). However, numerous factors that are associated with
older age are associated with an increased risk of depression. Possibly
the most important of these is medical co-morbidity, particularly chronic
long-term illness. Anxiety states (A) are extremely common in depression
in older age, and may in fact be the presenting feature. Deliberate selfharm
(B) is societally often seen as an act of the younger generations –
this is a dangerous misconception. Older people may also undertake acts
of deliberate self harm and remember these may not be associated with
depression, but may occur in the context of severe medical disability, pain
or loneliness. In fact, when older people do engage in acts of self-harm, this
is usually with a high level of suicidal intent and must be taken extremely
seriously. Depression is certainly not less common in residential care
settings (C) than in the general community. In nursing homes the rate may
be up to three times that of the community.
A 90-year-old woman is admitted to the psychiatric inpatient unit with severe
depression. She has the following medical history: end-stage chronic renal failure,
hypertension, type 2 diabetes controlled with oral hypoglycaemics, and has had
a stroke 3 years ago leaving her with some slight speech slurring. Which of the
following statements is false?
A. A serotonin specific reuptake inhibitor (SSRI) antidepressant would be a
safe choice
B. Benzodiazepines should not be prescribed routinely for this patient
C. Electroconvulsive therapy (ECT) would be contraindicated because of the
stroke
D. Lithium would not be the first line option
E. The patient’s diabetes will impact on the course and prognosis of her
depression
C. Electroconvulsive therapy (ECT) would be contraindicated because of the
stroke
ECT (C) is an important treatment for severe depression. It has a chequered
history and many opponents. There are very few, if any, absolute
contraindications to using ECT, and a stroke from 3 years ago would not
be considered a barrier to treatment. Relative contraindications include
heart disease, raised intracranial pressure and poor anaesthetic risk. SSRIs
(A) are generally thought to be safe in renal impairment. However, it
would be important to monitor renal function and urea and electrolytes,
particularly as older people and those with renal impairment are at a
higher risk of developing the syndrome of inappropriate antidiuretic
hormone secretion (SIADH) from SSRIs, leading to hyponatraemia.
Benzodiazepines (B) are not recommended for use in older age, and
depression itself would certainly not be an indication for their use. They
may cause increased confusion and falls. Lithium (D), while it may be
appropriate in severe refractory depression, would not be first line in
older age, and certainly not in someone with end-stage renal disease, as
it is renally excreted and now thought to be directly nephrotoxic. The
relationship between chronic disease, e.g. diabetes (E) and depression, is
well established.
An 84-year-old man is brought in to the psychiatric unit with a diagnosis of severe
depression with psychotic symptoms. He has had three previous admissions with
very similar symptoms. During his admission he begins voicing his desire to leave
the ward, claiming that the devil is possessing all of the staff and patients, and
that he is next. He claims that if he isn’t allowed to leave, he will do whatever he
can to escape the devil, even if this means ending his life. He has had to be moved
away from the door after trying to follow visitors out of the ward. What would be
the most appropriate course of action?
A. Detain him under common law for his own safety
B. Do nothing as staff have been able to coax him back on
to the ward
C. Place him on Section 3 of the Mental Health Act
D. Request an immediate Deprivation of Liberty Safeguard (‘DOLS’)
assessment under the Mental Capacity Act
E. Use intramuscular rapid tranquilization to alleviate his distress and keep
the ward safe
C. Place him on Section 3 of the Mental Health Act
This question requires you to have some knowledge about both the Mental
Capacity Act 2005 (‘MCA’) and the Mental Health Act 2007 (‘MHA’). It
is important that all healthcare professionals have knowledge relevant
to these acts as far as they may be required to use them – the MHA and
the MCA are not just the jurisdiction of psychiatrists, and all doctors
should know the fundamentals of assessing capacity as it is one of the
cornerstones of informed consent. There are numerous guides available
giving appropriate levels of information. Broadly speaking, the MCA
should not be used to detain someone if they have a mental illness. It may
be used to treat someone if that treatment is in their best interests and
they lack capacity to decide that treatment themselves. However, if there
is a clear indication that the person is suffering with a mental disorder,
is refusing treatment and especially if they pose a risk to themselves
or others, the MHA is likely to be the correct act to use. In this case, a
Section 3 (C) of the MHA would be the most appropriate as the patient is
known, and is presenting with similar symptoms to previous admissions.
This allows for treatment for up to 6 months. Detaining ‘under common
law’ (A) was used prior to the MCA coming into force to treat people
lacking capacity. If someone has capacity, you cannot treat them against
their will (although there are some unusual exceptions to this where
the MHA may be used). One cannot do nothing in this case (B) as the
man is at risk, both to himself and possibly others. Without any legal
framework neither he nor those around him have access to appropriate
safeguards (e.g. a tribunal). A Deprivation of Liberty Safeguards (DOLS)
assessment (D) is part of the MCA and applies when someone’s liberty is
being deprived rather than restricted – this does not apply here. There
is no evidence here that IM medication would be the most appropriate
course of action (E). Nursing and other management techniques should
be employed. IM medication should usually be a last resort and there is
nothing in the vignette to say he will not take oral medication.
Which of the following statements most accurately reflects manic syndromes in
older age?
A. All manic elderly patients should be detained under the Mental Health Act
B. Bipolar disorder resolves in later life
C. In bipolar disorder beginning in old age, most would have had episodes
of depression before a manic episode
D. Unipolar mania (i.e. mania occurring without episodes of depression) is
more common than bipolar disorder in older age
E. Unlike depression, physical co-morbidity does not have an impact on
manic syndromes in the elderly
C. In bipolar disorder beginning in old age, most would have had episodes
of depression before a manic episode
When ‘late-onset’ bipolar disorder occurs (C) (commonly taken to be
above the age of 50), the manic phase tends to present latently, often
many years following several depressive episodes. Not every manic
elderly person should be detained under the Mental Health Act (A) – each
individual must be assessed on a case-by-case basis. Bipolar disorder
does not disappear later in life (B). In fact, it has been suggested by
some that the frequency of episodes actually tends to increase in people
with long-standing bipolar disorder as they get older. There is probably
insufficient evidence, however, to be able to say this with much certainty.
Unipolar mania (D) does occasionally occur but, as with younger patients,
is fairly unusual.
An 80-year-old woman with a past medical history including hypertension,
diabetes and macular degeneration is admitted to accident and emergency
complaining of frightening images of birds swooping around her flat day and
night. At first she thought they were real but now realizes they could not be. She
has no past psychiatric history and apart from being very tearful about the images,
there is nothing else of note in the mental state. What is the most likely diagnosis?
A. Charles Bonnet syndrome
B. Cotard’s syndrome
C. Ekbom’s syndrome
D. Fregoli’s syndrome
E. Rett’s syndrome
A. Charles Bonnet syndrome
This is a very typical description of Charles Bonnet syndrome (A). This is
a syndrome of complex, vivid visual hallucinations that occur in people
with severe visual impairment (e.g. macular degeneration). Insight is
retained and there are no other symptoms (unless there is a co-morbid
diagnosis). It is usually self-limiting but there is no specific treatment as
such, although explaining the cause of the symptoms is often reassuring.
The other options are all eponymous syndromes related to psychiatry.
Cotard’s syndrome (B) is usually seen in psychotic depression, and is a
delusional state in which the sufferer believes a part of their body (or their
whole being) has ceased to exist. Ekbom’s syndrome (C), or delusional
parasitosis, is the delusional (not hallucinatory) belief that animals or
insects are crawling below the sufferer’s skin. It is a difficult syndrome
to treat because of the fixity of patients’ beliefs that their problem is a
physical one. Sufferers may engage in highly dangerous methods to rid
themselves of the ‘parasites’, such as digging them out with instruments
or using highly corrosive cleaning materials on the skin. Fregoli’s
syndrome (D) is a form of delusional misidentification, in which sufferers
believe that complete strangers are actually people well known to them
in disguise. Rett’s syndrome (E) is a dominantly inherited X-linked
developmental disorder seen almost exclusively in girls and is associated
with severe physical and learning disabilities.
A 74-year-old widowed woman, previously fit and well with no past psychiatric
history, presents to her GP to ‘have it out once and for all about these bloody
neighbours’. She says for the last month her neighbours have been spying on
her and are leaking radiation through her ceiling which is making her cough
incessantly. On examination she does indeed have a severe cough and has lost
weight since her last appointment 3 months ago. Otherwise she looks fairly healthy
and well kempt, with an Mini-Mental State Examination (MMSE) of 29/30. Which
of the following statements is the most accurate?
A. Antipsychotics are likely to have a rapid and successful effect
B. Rehousing is likely to be the most effective treatment
C. The cough is a delusional elaboration of her other symptoms
D. The most likely diagnosis is an early dementia
E. The most likely diagnosis is very late-onset schizophrenia-like psychosis
(VLOSLP)
E. The most likely diagnosis is very late-onset schizophrenia-like psychosis
(VLOSLP)
VLOSLP (E), despite its unwieldy name, is considered by many old age
psychiatrists to be an extremely well-circumscribed syndrome, although
the literature is still somewhat confusing. This used to be termed ‘late
paraphrenia’ but this term is currently not in vogue and probably
therefore best avoided. VLOSLP typically affects women more than men
and sufferers often have no other personality or cognitive problems.
Delusions can take any form, but it is very common for sufferers to
describe ‘partition delusions’, in which solid structures become permeable
to people or substances – in this case radiation from the neighbours.
Unfortunately, the response to antipsychotics (A) tends to be relatively
poor. There may be some success but they are unlikely to alleviate all
symptoms. Sufferers tend to live alone and be extremely lonely, so
befriending or more formal psychological intervention may offer some
relief.
Which of the following statements concerning alcohol misuse in older age is the
most accurate?
A. Alcohol dependence almost always begins in earlier life
B. Alcohol dependence is easier to spot in elderly people
C. Genetic factors do not have an influence on alcohol misuse in older age
D. Heavy alcohol use may lead to dementia
E. The male:female ratio is much lower in older people with alcohol misuse
than in the young
D. Heavy alcohol use may lead to dementia
There are several misconceptions concerning alcohol use and misuse
in older people. Moderate use, harmful use and dependence on
alcohol are all seen in older age, and are not uncommon. Alcohol
should routinely be asked about when assessing older people, and
it is important that you learn the skills of how to do this. Alcohol
dementia (D) is a complex phenomenon as it may be the result
of different pathologies. Prolonged and heavy alcohol misuse is
associated with irreversible cognitive problems. Alcohol use may
predispose to cerebrovascular disease, head injury (and subsequent
Alzheimer’s disease) as well as having a directly toxic effect on the
brain. Korsakoff’s syndrome may also occur with prolonged use, which
in itself is an amnestic syndrome. Alcohol dependence may certainly
arise de novo in older people (A). It may be precipitated by stressful
life events. However, this does not mean that genetics (C) do not play
a role in the aetiology of alcohol dependence in older people, whether
this is because of dependence from a younger age extending into older
age, or arising de novo. Alcohol problems are often covert in older
people (B). Cognitive problems may also lead to a poor recollection of
alcohol use. The consequences of alcohol misuse may be concentrated
upon (e.g. recurrent falls) rather than the alcohol use itself. There is
still a male preponderance in alcohol problems in older age (E).
Which of the following statements concerning anxiety in older age is the most
accurate?
A. Cognitive behavioural therapy (CBT) is less effective in older age than in
younger patients
B. Inpatient management of anxiety is the most successful setting for
treatment
C. Men are more likely to develop anxiety disorders than women in older age
D. Poor physical health is not associated with the onset of anxiety
disorders
E. Worries over physical health are more common in older adults with
anxiety
E. Worries over physical health are more common in older adults with
anxiety
Anxiety disorders in older age behave fairly similarly to anxiety disorders
in younger patients. However, there are certain things to bear in mind.
One is that, in a similar way to depression, anxiety in older people may
focus around issues related to physical health (E). Also, while both CBT
and antidepressants are effective (A), medication may need to be tailored
to the individual with more care – SSRIs may cause gastrointestinal
bleeding, for example, and tricyclics may exacerbate falls because of
their anticholinergic effects. There would be no reason to treat anxiety
disorders in older people as inpatients (B) unless there were compelling
issues around risk – this is true regardless of age.
A 71-year-old man, previously fit and well, presents to his GP with his wife who
states he has ‘lost his marbles’ over the last 2 months, with worsening memory
loss. He scores 21/30 on the MMSE, losing points mainly on recall as well as
dysphasia. His wife has also noticed that he has lost weight. Routine blood tests
show the following:
Na+: 129mmol/L
K+: 4.4mmol/L
Adjusted Ca2+: 3.1mmol/L
What is the most likely diagnosis?
A. Addison’s disease
B. Cerebral malignancy
C. Cushing’s disease
D. Hyperthyroidism
E. Primary hyperparathyroidism
B. Cerebral malignancy
Cerebral malignancy (B) (whether primary or secondary) may present
with memory loss and dysphasia. Frontal lobe tumours, because of
their location, may lead to very few other localizing signs, so do not
presume the absence of either soft or obvious neurological signs rules
out the presence of brain malignancy. The biochemical abnormalities
show hyponatraemia, hypercalcaemia and a normal potassium level.
This would be consistent with brain malignancy, as many tumours may
produce parathyroid-related peptide which will lead to hypercalcaemia,
although this would commonly be from secondary metastatic disease
in the brain from a haematological malignancy or solid tumour such
as breast or lung. New presentation of hypercalcaemia should always
prompt suspicion for malignancy. The hyponatraemia similarly results
from inappropriate secretion of ADH (SIADH). This may result directly
from an ADH-secreting tumour (or one secreting atrial natriuretic
peptide), which again is often lung but may also be head and neck
tumours. Unexplained weight loss should also raise the possibility
of occult malignancy.
A 90-year-old woman is in hospital with late-stage colon cancer which has
metastasized. She has been remarkably well all her life before being diagnosed with
cancer. She lost her husband 3 years ago but has a supportive family. On the ward,
she develops a chest infection. The consultant wants to start her on antibiotics, but
she says she does not want them. The consultant asks for a psychiatric opinion,
worried that she is depressed. However, the psychiatrist reports she is not depressed
and is fully competent to make this decision and is choosing how to die as she
wishes. What ethical concept is best described here?
A. Autonomy
B. Beneficence
C. Capacity
D. Justice
E. Non-maleficence
A. Autonomy
Ethical questions seldom have ‘one single best’ answer but you are asked
here to describe which best fits the description. Autonomy (A) refers to
the ethical concept of the right to make one’s own decisions. In patients
with capacity to make the decision in question, autonomy must be
respected. This is not the same as necessarily autonomy being followed,
as there may be examples when other ethical considerations will override
autonomy, such as when there is significant risk to the public etc. In this
case, the woman is making a decision, with full capacity, that she does
not want any further treatment.
Which of the following statements is true about medicines use in older age?
A. Antipsychotics are the drugs of choice for behavioural disturbance in
dementia
B. Fat-soluble drugs, such as diazepam, will have a longer duration of
action because of increased body fat in older people
C. Lithium doses in older people should generally be lower because the
liver cannot excrete it as efficiently
D. Older people are less sensitive to the effects of benzodiazepines
E. Tricyclic antidepressants (TCA) will not cause constipation in older
people because of a general increase in gut motility
B. Fat-soluble drugs, such as diazepam, will have a longer duration of
action because of increased body fat in older people
As we age, there is a general increase in our body fat, with less body
water. This leads to an increased volume of distribution. For drugs
that are fat-soluble, such as diazepam (B), this means there will be
a general increase in the duration of action. This is important when
using these drugs as it will become easier to inadvertently overdose
the patient. Antispsychotics (A) have been shown to increase all-cause
mortality in patients with dementia and are therefore to be avoided
wherever possible
