Old age psychiatry Flashcards
What is part of a confusion screen?
- FBC (anaemia, infection)
- U&Es (renal failure, hypercalcaemia)
- CRP (infection)
- LFTs (hepatic encephalopathy)
- Thyroid function
- B12 & folate
What are the SPACE principles when working with someone with confusion?
- Staff who are skilled and have time to care
- Partnership working with carers
- Assessment and early identification
- Care that is individualised
- Environments that are dementia/delirium friendly (plain floors, signs with diagrams, contrasting colours)
What can assist when caring for someone with confusion?
Ensure glasses and hearing aids are working.
Having clocks, whiteboards to orient place, date, weather etc.
Ensure newspapers are the correct date and nightclothes are only worn at night.
Try and have someone sit with her (eg nurse does her paperwork by the bedside)
What is involved in a 4AT score?
1) Alertness
2) AMT4 (Age, DOB, place, current year)
3) Attention (months of year in reverse
4) Acute change or fluctuating course
What does the 4AT score show?
Likelihood of delerium
4 or above: possible delirium +/- cognitive impairment
1-3: possible cognitive impairment
0: delirium or severe cognitive impairment unlikely (but delirium still possible if [4] information incomplete)
What should be done pharmacology-wise when a pt is confused?
Reduce anti-cholinergic medication
Oxybutinin, amitriptiline, atenolol, nytol, ranitidine, paroxetine
Avoid constipation (codeine)
What can cause delirium?
Acute or subacute: • Brain syndrome • Confusional state (nonalcoholic) • Infective psychosis • Organic reaction • Psycho-organic syndrome
Is delirium rare?
No, very common, 10-30% of pt on admission, 80% on ITU
What is dementia?
Syndrome due to disease of the brain. Usually chronic/progressive in nature. Disturbance of multiple higher cortical functions (memory, thinking, orientation, comprehension, calculation, learning capacity, judgement)
Consciousness is not affected
98% is after age 65
Must be present for at least 6 months
What is Alzheimer’s?
62% of dementias
Extracellular ß-amyloid plaques and intracellular tau-tangles
Cortical atrophy (esp hippocampus)
Insidious decline in short term memory, language and judgement
Prognosis 5-10yrs from diagnosis
Is Alzheimer’s disease genetic?
Genetic link- FH doubles risk (apolipoprotein E4)
Early onset Alzheimer’s is autosomal dominant (amyloid precursor protein, presenelin 1&2 mutations)
Treatment of Alzheimer’s disease?
Acetylcholinesterase inhibitors (avoid in CV patients, peptic ulcers and COPD)
What is vascular dementia?
17% of dementias
• Multiple infarctions (TIA) and small vessel disease cause cerebrovascular disease-> cognitive deficit
• Abrupt onset, step-wise deterioration
• Patchy cognitive deficits
• Hypertension, history of stroke, CT/MRI imaging of infarction and periventricular white matter lesions
What is Lewy Body Dementia?
4-10% of dementias
• Intracellular accumulations of alpha-synuclein in substantia nigra neurons and cortex
• Fluctuating cognition
• Parkinsonism (not drug induced)
• Visual hallucinations
• Other features include: REM sleep behaviour disorder, severe neuroleptic sensitivity, low dopamine uptake in the basal ganglia (DaTscan)
What can you not give someone with Lewy Body dementia?
Antipsychotics
What is frontotemporal dementia?
• 2-5%
SPECT scanning is used to differentiate it from Alzheimer’s
• Pick’s disease (females, 60, death in 6-8yrs)
• Disinhibition and loss of social awareness
• Insideous onset, slow progression
• Emotional change and impulsivity
• Hyperorality (insertion of objects into mouth)
• Speech deficits
What are the behavioural and psychological symptoms of dementia?
- Agitation-> aggression and irritability
- Paranoia
- Delusions & hallucinations
- Depression and anxiety
- Disinhibition and repeated questioning
- Sleep disturbance
- Persistent vocalisation and screaming
- Reduced appetite
- Wandering
What is delirium?
An etiologically nonspecific organic cerebral syndrome characterised by concurrent disturbances of consciousness and attention, perception, thinking, memory, psychomotor behaviour, emotion, and the sleep-wake schedule. The duration is variable and the degree of severity ranges from mild to very severe.
Developed over a short period of time and fluctuates
Evidence of a physical cause
Name 4 risk factors for delirium
- Sensory impairment
- Pre-existing dementia
- Acute illness
- Older age
Name some acetylcholine esterase inhibitors (AChEi)
Donepezil
Galantamine
Rivastigmine
What drugs can be used in dementia other than AChEi?
NMDA receptor antagonists (Memantine)
Used when ACEi are contraindicated/not tolerated or if AD is severe
If a dementia pt gets anxious and delusional, what can be done?
ONLY use antipsychotics if severely distressed or immediate harm to the pt or others
-> increased risk of stroke, Lewy Body-> neuroleptic sensitivity reactions
Benzodiazepine is another option (lorazepam, haloperidol)
What is done in memory clinic?
Collateral Hx from partner/child How have things changed over the past year? (gradual, step wise?) Behaviour (getting lost, driving, frustration/aggression, relationships) Mood Personal care Physical health Daily routine Carer stress
What should be ruled out when diagnosing dementia?
Hypothyroidism, Hypercalcaemia Vitamin B12 deficiency, niacin deficiency Neurosyphilis Normal pressure hydrocephalus Subdural haematoma Depression Delirium Mental retardation vCJD Huntington's
What is early onset Alzheimer’s disease?
Dementia in Alzheimer’s disease beginning before the age of 65. There is relatively rapid deterioration, with marked multiple disorders of the higher cortical functions.
Aphasia, agraphia, alexia, and apraxia occur relatively early in the course of the dementia in most cases.
FH
In what groups is depression more likely?
Physical illness
Dementia
Bereavement
What does depression in old age present with?
Disturbed sleep
Multiple physical problems with no cause found
Motor disturbance (retardation/agitation)
Dependency
How can depression be managed in older age?
CBT Medication (SSRIs, mirtazipine) Reduce social isolation (day centres) Reduce sensory isolation (glasses, hearing aids) ECT if severe
Which antidepressants should be avoided in older age?
TCAs (postural hypotension-> falls)
Risk factors for older age schizophrenia
Sensory deprivation (deafness) Social isolation
What is more common after frontal lobe injuries?
Personality and behaviour changes
- > disinhibition
- > aggression
- > impulsivity
- > apathy
What is more common after temporal lobe injury?
Psychosis
Name 5 psychiatric complications of Parkinson’s
Depression and anxiety (limbic pathway dysfunction)
Dementia
Psychosis
Apathy
Impulsive and compulsive behaviours (gambling, compulsive shopping) due to dopaminergic therapy
Name 5 differences between dementia and delirium
Delirium Dementia
Rapid deterioration Slow
Fluctuating course Progressive
Clouded consciousness Alert
Vivid, complex, muddled Impoverished thought
Hallucinations common less common
Give examples of cortical versus subcortical dementias
Cortical (Alzheimer's, Lewy Body, Frontotemporal) Sub cortical (Parkinson's, Huntington's, AIDS, alcohol related)
Describe normal pressure hydrocephalus
Idiopathic/SAH/head injury/meningitis Mental slowness Apathy Wide based gait Urinary incontinence
