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Psych Y5 > Old Age Psychiatry > Flashcards

Old Age Psychiatry Flashcards

1
Q

How to assess dementia in clinic?

A

Cognitive - ACE etc.
ADLs - family, OT
Falls risk - PT
Biological - bloods, scan

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2
Q

What are the 4 criteria required for dementia?

A

Significant
Global
Acquired
Cognitive impairment

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3
Q

Clinical features of AlzD?

A

Insidious onset
Functional impairment
Cognitive decline - memory, aphasia, apraxia, agnosia, executive function loss
Behavioural signs later

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4
Q

What psychological therapy may be of use in mild-moderate AlzD?

A

Memory remediation

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5
Q

What are 3 AChIs?

A

Donepezil
Galantamine
Rivastigmine

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6
Q

What drug is often first line for mild/mod AlzD?

A

Donepezil - AChI

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7
Q

What MMSE roughly may indicate mild-moderate AlzD?

A

10-25

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8
Q

What MMSE score may indicate severe dementia?

A

Less than 10

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9
Q

What advantage does donepezil have over other dementia drugs in terms of treatment regime?

A

Only OD vs BD for others

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10
Q

Which AChI is particularly bad for vomiting side effects?

A

Rivastigmine

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11
Q

Which dementias are AChI licensed for?

A

AlzD

DLB

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12
Q

What effectiveness do AChIs have for dementia?

A

May slow rate of progression without altering outcome
May have small benefit in cognition
May also improve function

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13
Q

How quickly would a patient with AlzD expect their MMSE to reduce?

A

By roughly 3 points per year

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14
Q

What are the main side effects of AChIs? Think opposite of Anticholinergics

A 
Nausea and vomiting
Dizziness and falls
Diarrhoea
Anorexia 
Abdominal pain
Headache, nightmares
Muscle craps, sweating
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15
Q

Contraindications to AChI use?

A

Cardiac - heart block, sick sinus syndrome
Asthma, COPD - can worsen
Ulcers and increased risk GI bleed

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16
Q

What non-AChI option is available for AlzD?

A

Memantine - a glutamate inhibitor

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17
Q

What is the basis behind function of memantine?

A

Neuron death leads to excess cellular production of glutamate, which is toxic and causes further neuronal damage
Memantine is an antagonist of glutamate, having neuroprotective effects and promoting synaptic plasticity

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18
Q

When may memantine be useful?

A

Severe AlzD
Moderate AlzD with intolerance to AChI
In people intolerant to AChI

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19
Q

Limitations of memantine?

A

Dizziness although less than donepezil
Hypertension
Overarousal or sedation
Constipation

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20
Q

3 drugs interactions with memantine?

A

Warfarin - bleed risk
Ranitidine - GI upset
NMDA antagonists

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21
Q

3 contraindications to memantine use?

A

Cardiac failure
Renal failure
Epilepsy

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22
Q

Is donepezil or memantine worse for causing dizziness?

A

Donepezil

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23
Q

Which commonly used AlzD drug must be tapered if stopping?

A

Rivastigmine

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24
Q

When would assess response to AlzD drugs?

A

After 3m or sooner if side effects

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25
What are BPSD?
Behavioural and psychological symptoms in dementia
26
6 common BPSDs of dementia?
``` Depression Anxiety Aggression Wandering Sleep disturbance Psychosis ```
27
What specific drugs are first line for agitation or aggression in dementia?
Risperidone | Amisulpride
28
If starting antipsychotics in dementia what are the 3Ts to consider?
Titration of dose Target a symptom Time limited - review after 3m at latest
29
Risks of using antipsychotics in AlzD or VaD?
Increased risk of stroke and or death
30
Risk of using antipsychotics in DLB?
Risk of NMS/death or symptom worsening
31
Clinical features of vascular dementia?
Abruptish onset, stepwise progression Day to Day variability Relatively preserved insight and personality Vasculopath signs and history Focal neurology esp if larger infarcts, or gait/bulbar disturbances
32
What 4 phenotypes of vascular disease can contribute to the development of vascular dementia?
Large vessel disease e.g. Ischaemia stroke Small vessel occlusion Partial vessel occlusion Hypotensive episodes
33
What lesions do hypotensive episodes lead to in brain?
White matter lesions
34
What mental health comorbidity is common in vascular dementia and how do you manage it?
Depression - should treat medically with e.g. Trazodone
35
How should you manage BPSDs in VaD?
Antipsychotics e.g. Risperidone, quetiapine, amisulpride, haloperidol High degree of caution and risk benefit analysis considering stroke risk
36
What cognitive feature is characteristically lost early in DLB?
Attention and train of thought
37
How do you manage psychosis in DLB?
Reduce PD meds AChIs and poss memantine Consider atypical antipsychotics with caution (NMS, death risk)
38
What dementing process is an important differential for delirium?
DLB
39
DELIRIUM of medical causes of delirium?
``` Drugs and alcohol Ears/eyes (glasses, hearing aids) Low O2 (MI, stroke, PE, acute event) Infection (commonly chest, urine) Retention of urine, constipation Ictal states Undernutrition, dehydration Metabolic (DM, hypoglycaemia, post op, Na) ```
40
What does NICE guidance suggest about managing agitated delirium?
Consider short term (1 week or less) haloperidol or olanzapine Start low dose and titrate to symptoms
41
Prognosis/death rate of delirium?
Up to 40%
42
What is Ribot's law?
Dictates that memories are lost from recent to past in dementing process
43
What are the core symptoms of later life depression?
Less likely to complain of low mood or sadness More likely to present with cognitive impairment, behaviour disturbance e.g. Psychomotor change, physical health deterioration Anxiety symptoms more common - somatisation, hyperchondriasis Delusions and paranoia also more common
44
Common biopsychosocial factors contributing to later life depression?
Biological - physical illness e.g. CVD, dementia Psychological - death of spouse, loss of role/job, personality traits Social - loneliness, retirement, reduced independence
45
In whom is mirtazapine recommended for depression therapy?
Good sedative and good for somatic Sx of anxiety Also leads to weight gain so good for more frail patients Lower risk of bleeding associated with e.g. SSRIs
46
What is first line for depression in the elderly?
SSRIs e.g. Sertraline, fluoxetine | Or mirtazapine in those in whom it is deemed suitable
47
How long would you generally medicate for in an elderly person with moderate or worse depression? What does this effect?
At least 12-24m | Treating for at least 2 years after recovery reduces risk of relapse or recurrence to around 1/3
48
4 important things to consider when prescribing psychotropics in the elderly?
Physiological age related changes e.g. Reduced renal excretion Other physical comorbidities which may worsen Polypharmacy and drug interactions Drug side effect profiles
49
What is an important metabolic side effect of SSRI therapy esp in elderly?
Hyponatraemia
50
5 predictors of poor outcomes in depressed elderly?
``` Very elderly Medical comorbidities Co morbid anxiety White matter lesions on mri esp frontal Frontal executive dysfunction predicts poor med response ```
51
How do you take a lithium level? How do you interpret?
Measure 10-12 hours after last dose 0.5-0.8 is ideal for the elderly Generally over 1 is dangerous
52
Major side effects of lithium getting towards toxicity?
GI - anorexia, nausea, diarrhoea | CNS - muscle weakness, drowsiness, disorientation, ataxia, coarse tremor, muscle twitching
53
Can lithium be toxic even in normal range?
Yes esp in the elderly
54
LITHIUM of lithium OD?
``` Levels - therapeutic (0.6-1.2) Increased urination Thirst and tremor Headache Increase fluids Unsteady Mortons salt adequate intake ```
55
4 surgical causes of reversible cognitive impairment?
Subdural Normal pressure hydrocephalus SOLs Empyema or intracranial abscess
56
7 infectious/inflammatory causes of reversible cognitive impairment?
``` Lyme Syphilis Whipple's disease Sarcoidosis Cerebral vasculitis Encephalitis - limbic, HIV, HSV Meningitis - fungal, malignant, tubercular ```
57
9 metabolic causes of reversible cognitive impairment?
``` Thyroid up or down Hashimoto's encephalitis Parathyroid up or down, hypercalcaemia Pituitary insufficiency Cushings or Addison's Hypoglycaemia Vitamin def incl B1, 6, 12 and folate Chronic liver, renal or respiratory failure Wilson's disease ```
58
4 misc causes of reversible cognitive impairment?
Drugs and alcohol Depression Epilepsy Sleep apnoea
59
Where does AlzD effect and how?
Temporal and parietal lobes Cortical degeneration due to B amyloid plaques disrupting neuronal transmission, Ach production reducing from effect neurons and toxic apoptosis
60
What are the 2 major genetic factors influencing heredity in AlzD?
ApoE4 variant | PSEN
61
Early Sx of AlzD?
Early memory lapses - people's names, places, word finding, appointments etc.
62
Progressive Sx of AlzD?
Language difficulties Apraxia Planning and decision making difficulties Confusion
63
Late Sx of AlzD?
``` Wandering and disorientation BPSDs Altered eating habits Incontinence Psychotic Sx ```
64
What syndrome may have abnormal HMPAO/SPECT imaging studies?
Down's syndrome
65
What is binswangers disease?
Subcortical leukoencephalopathy - small vessel vascular dementia due to white matter damage Often related to old age, chronic HTN Causes a subcortical dementia
66
What is subcortical dementia?
Mental manipulation - impaired executive function but without deterioration in episodic or declarative memory Personality - irritability, apathy Emotional changes incl depression Later on memory problems like cortical dementia
67
Diagnostic criteria for DLB?
Dementia plus at least 2 of: Fluctuating attention/concentration Recurrent well formed visual hallucinations Spontaneous Parkinsonism
68
Suggestive features of DLB?
REM sleep behavioural disorder Severe neuroleptic sensitivity SPECT imaging showing low dopamine uptake in striatum
69
First line med for DLB associated cognitive impairment?
Rivastigmine
70
Of the 3 most common causes of dementia which has the worst prognosis?
Vascular
71
What are the 3 clinical syndrome of FTD?
Behavioural variant Progressive non-fluent aphasia Semantic dementia

Psych Y5 (13 decks)

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