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Psych Y5 > Old Age Psychiatry > Flashcards

Old Age Psychiatry Flashcards

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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
Q

What are BPSD?

A

Behavioural and psychological symptoms in dementia

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26
Q

6 common BPSDs of dementia?

A 
Depression
Anxiety
Aggression
Wandering
Sleep disturbance
Psychosis
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27
Q

What specific drugs are first line for agitation or aggression in dementia?

A

Risperidone

Amisulpride

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28
Q

If starting antipsychotics in dementia what are the 3Ts to consider?

A

Titration of dose
Target a symptom
Time limited - review after 3m at latest

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29
Q

Risks of using antipsychotics in AlzD or VaD?

A

Increased risk of stroke and or death

30
Q

Risk of using antipsychotics in DLB?

A

Risk of NMS/death or symptom worsening

31
Q

Clinical features of vascular dementia?

A

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
Q

What 4 phenotypes of vascular disease can contribute to the development of vascular dementia?

A

Large vessel disease e.g. Ischaemia stroke
Small vessel occlusion
Partial vessel occlusion
Hypotensive episodes

33
Q

What lesions do hypotensive episodes lead to in brain?

A

White matter lesions

34
Q

What mental health comorbidity is common in vascular dementia and how do you manage it?

A

Depression - should treat medically with e.g. Trazodone

35
Q

How should you manage BPSDs in VaD?

A

Antipsychotics e.g. Risperidone, quetiapine, amisulpride, haloperidol
High degree of caution and risk benefit analysis considering stroke risk

36
Q

What cognitive feature is characteristically lost early in DLB?

A

Attention and train of thought

37
Q

How do you manage psychosis in DLB?

A

Reduce PD meds
AChIs and poss memantine
Consider atypical antipsychotics with caution (NMS, death risk)

38
Q

What dementing process is an important differential for delirium?

A

DLB

39
Q

DELIRIUM of medical causes of delirium?

A 
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
Q

What does NICE guidance suggest about managing agitated delirium?

A

Consider short term (1 week or less) haloperidol or olanzapine
Start low dose and titrate to symptoms

41
Q

Prognosis/death rate of delirium?

A

Up to 40%

42
Q

What is Ribot’s law?

A

Dictates that memories are lost from recent to past in dementing process

43
Q

What are the core symptoms of later life depression?

A

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
Q

Common biopsychosocial factors contributing to later life depression?

A

Biological - physical illness e.g. CVD, dementia
Psychological - death of spouse, loss of role/job, personality traits
Social - loneliness, retirement, reduced independence

45
Q

In whom is mirtazapine recommended for depression therapy?

A

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
Q

What is first line for depression in the elderly?

A

SSRIs e.g. Sertraline, fluoxetine

Or mirtazapine in those in whom it is deemed suitable

47
Q

How long would you generally medicate for in an elderly person with moderate or worse depression? What does this effect?

A

At least 12-24m

Treating for at least 2 years after recovery reduces risk of relapse or recurrence to around 1/3

48
Q

4 important things to consider when prescribing psychotropics in the elderly?

A

Physiological age related changes e.g. Reduced renal excretion
Other physical comorbidities which may worsen
Polypharmacy and drug interactions
Drug side effect profiles

49
Q

What is an important metabolic side effect of SSRI therapy esp in elderly?

A

Hyponatraemia

50
Q

5 predictors of poor outcomes in depressed elderly?

A 
Very elderly
Medical comorbidities
Co morbid anxiety
White matter lesions on mri esp frontal
Frontal executive dysfunction predicts poor med response
51
Q

How do you take a lithium level? How do you interpret?

A

Measure 10-12 hours after last dose
0.5-0.8 is ideal for the elderly
Generally over 1 is dangerous

52
Q

Major side effects of lithium getting towards toxicity?

A

GI - anorexia, nausea, diarrhoea

CNS - muscle weakness, drowsiness, disorientation, ataxia, coarse tremor, muscle twitching

53
Q

Can lithium be toxic even in normal range?

A

Yes esp in the elderly

54
Q

LITHIUM of lithium OD?

A 
Levels - therapeutic (0.6-1.2)
Increased urination
Thirst and tremor
Headache
Increase fluids
Unsteady
Mortons salt adequate intake
55
Q

4 surgical causes of reversible cognitive impairment?

A

Subdural
Normal pressure hydrocephalus
SOLs
Empyema or intracranial abscess

56
Q

7 infectious/inflammatory causes of reversible cognitive impairment?

A 
Lyme
Syphilis
Whipple's disease
Sarcoidosis
Cerebral vasculitis
Encephalitis - limbic, HIV, HSV
Meningitis - fungal, malignant, tubercular
57
Q

9 metabolic causes of reversible cognitive impairment?

A 
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
Q

4 misc causes of reversible cognitive impairment?

A

Drugs and alcohol
Depression
Epilepsy
Sleep apnoea

59
Q

Where does AlzD effect and how?

A

Temporal and parietal lobes
Cortical degeneration due to B amyloid plaques disrupting neuronal transmission, Ach production reducing from effect neurons and toxic apoptosis

60
Q

What are the 2 major genetic factors influencing heredity in AlzD?

A

ApoE4 variant

PSEN

61
Q

Early Sx of AlzD?

A

Early memory lapses - people’s names, places, word finding, appointments etc.

62
Q

Progressive Sx of AlzD?

A

Language difficulties
Apraxia
Planning and decision making difficulties
Confusion

63
Q

Late Sx of AlzD?

A 
Wandering and disorientation 
BPSDs
Altered eating habits
Incontinence
Psychotic Sx
64
Q

What syndrome may have abnormal HMPAO/SPECT imaging studies?

A

Down’s syndrome

65
Q

What is binswangers disease?

A

Subcortical leukoencephalopathy - small vessel vascular dementia due to white matter damage
Often related to old age, chronic HTN
Causes a subcortical dementia

66
Q

What is subcortical dementia?

A

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
Q

Diagnostic criteria for DLB?

A

Dementia plus at least 2 of:
Fluctuating attention/concentration
Recurrent well formed visual hallucinations
Spontaneous Parkinsonism

68
Q

Suggestive features of DLB?

A

REM sleep behavioural disorder
Severe neuroleptic sensitivity
SPECT imaging showing low dopamine uptake in striatum

69
Q

First line med for DLB associated cognitive impairment?

A

Rivastigmine

70
Q

Of the 3 most common causes of dementia which has the worst prognosis?

A

Vascular

71
Q

What are the 3 clinical syndrome of FTD?

A

Behavioural variant
Progressive non-fluent aphasia
Semantic dementia

Psych Y5 (13 decks)

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