Old Age Psychiatry

Question 1

What is delirium?

Answer 1

An acute, transient, global, organic disorder of higher nervous system function involving altered consciousness and attention

Question 2

What does the DSM IV / ICD-10 require for the diagnosis of delirium?

Answer 2

Altered consciousness PLUS perceptual / cognitive impairment PLUS sudden onset with fluctuations PLUS evidence of organic aetiology

Question 3

How is delirium managed?

Answer 3

• Identify and treat underlying organic cause e.g. infection
• Stable environment for the patient e.g. consistent staffing, good lighting, safe environment
• Medication for psychosis e.g. low, single-dose antipsychotic (haloperidol)
• Regular review

Question 4

Give 4 types of dementia

Answer 4

Alzheimer’s disease
Vascular dementia
Lewi body dementia
Fronto-temporal lobe dementia

Question 5

What is the most common type of dementia?

Answer 5

Alzheimer’ disease - Accounts for 50-70% of dementias

Question 6

What is dementia?

Answer 6

An acquired syndrome where there is progressive decline in cognitive, intellectual functioning and a change in personality with behavioural problems affective the activities of daily living

Question 7

What is the diagnostic criteria for ‘probable Alzheimer’s Disease’?

Answer 7

• Impairment of 2 or more domains of cognition
• Progressive loss of memory and other cognitive function
• No disturbance of consciousness
• Onset between 40 and 90 years old

Question 8

What is the ‘supporting criteria’ for diagnosis of Probable Alzheimer’s Disease?

Answer 8

• Progressive deterioration of language, motor skills, perception
• Evidence of cerebral atrophy on CT scan
• Worsening ability to perform ADLs
• Family history of Alzheimer’s disease
• Normal EEG

Question 9

What is the diagnostic criteria for ‘Definite Alzheimer’s Disease’?

Answer 9

All the criteria of ‘Probable’, but with the addition of histopathological changes on biopsy or autopsy

Question 10

Mutations in which genes are thought to be responsible for ‘early onset’ Familial Autosomal Dominant Alzheimer’s Disease?

Answer 10

• Amyloid Precursor Protein (APP)

- Presenilin 1 and 2

Question 11

Which sex is at higher risk of Alzheimer’s?

Answer 11

Female

Question 12

Give the names of 3 cholinesterase inhibitors used in the treatment of Alzheimer’s

Answer 12

Donepazil
Rivastigmine
Galantamine

Question 13

Give the name of an NMDA receptor antagonist used in the treatment of Alzheimer’s

Answer 13

Memantine - Reserved for late stages of the disease process

Question 14

What is the most common sign elicited on neurological examination of a patient with vascular dementia?

Answer 14

Reflex asymmetry

Question 15

What are the 3 central features of dementia with Lewy bodies?

Answer 15

• Dementia i.e. progressive cognitive decline
• Memory impairment as the disease progresses
• Deficits of attention, visuospacial ability, executive function

Question 16

What are the 3 core features of dementia with Lewy bodies?

Answer 16

• Visual hallucinations
• Extra-pyramidal signs
• Fluctuating cognition, variation in attention and alertness

Question 17

What is the first line therapy for depression in older people?

Answer 17

SSRIs

Question 18

Give 3 options which may be used as 2nd line therapy for depression in older people

Answer 18

Venlafaxine
Mirtazepine
Trazodone

Question 19

True / False: Older people who attempt suicide are more likely to succeed than younger people who attempt suicide

Answer 19

True

Question 20

What is the most common symptom of psychosis in elderly people?

Answer 20

Persecutory delusions

Question 21

True / False: Negative symptoms, first-rank symptoms of schizophrenia, and thought disorder is common in psychosis of elderly people

Answer 21

False - These are UNCOMMON

Question 22

Which 5 cognitive domains are assessed by the MMSE?

Answer 22

Orientation
Registration
Attention
Calculation
Language

Question 23

Give 4 tests which could evaluate a patient’s cognitive function

Answer 23

Mini Mental State Examination (MMSE)
CLOX1
Confusion Assessment Method (CAM)
Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE)

Question 24

Which domain of cognition is assessed using the CLOX1 test?

Answer 24

Executive function

Question 25

Give 3 tools which might help in the assessment and diagnosis of a patient for dementia

Answer 25

MMSE - Mini Mental State Examination
MOCA - Montreal Cognitive Assessment
ACE-III - Adenbrooke’s Cognitive Examination

Question 26

What is the gold standard diagnostic test for Alzheimer’s disease?

Answer 26

National Institute of Neurological and Communicative Disorders and Stroke; Alzheimer’s Disease and Related Disorders (NINCDS-ADRDA)

Question 27

Which type of dementia classically gives a step-wise deterioration?

Answer 27

Vascular dementia

Question 28

True / False: Treatment for vascular dementia is the same as for Alzheimer’s dementia

Answer 28

False

Drugs used in the treatment of Alzheimer’s are NOT indicated in the treatment of vascular dementia. The treatment of vascular dementia is focussed on treating the vascular cause to prevent further decline. This means reducing smoking etc, and optimising BP / diabetes control etc.

Question 29

What treatment is available for Lewy Body dementia?

Answer 29

Rivastigmine - may help with visual hallucinations and cognition
Clonazepam - For REM sleep disturbance
Psychological therapies as with the other types of dementia

Question 30

Which physical observation is it most important to monitor with the use of anti cholinesterase inhibitors? Why?

Answer 30

Heart rate - These drugs can cause bradycardia and can cause arrhythmias, syncope and collapse in patients with heart block

Question 31

What are the 3 ‘suggestive’ features of Lewy Body dementia?

Answer 31

REM sleep disturbance
Hypersensitivity to neuroleptics
Low dopamine transporter uptake in basal ganglia demonstrated on imaging

Question 32

What is the key investigation in Lewy Body dementia?

Answer 32

DAT scan