Old Age Psychiatry Flashcards
What are the ABCD’s of dementia?
A for Acitivities of Daily Living (ADLs)
B for Behavioural and Psychiatric Symptoms of Dementia (BPSD)
C for Cognitive Impairment
D for Decline
What are the cognitive features of dementia?
Memory (dysmnesia)
Plus one or more of
- dysphasia (communication)
- expressive
- receptive
- dyspraxia (inability to carry out motor skills)
- dysgnosia (not recognising objects)
- dysexecutive functioning
Delirium
* Abrupt, precise onset, known date
* Acute illness, lasting days or weeks
* Usually reversible
* Disorientation early in illness
* Variable, hour by hour
* Prominent physiological changes; increased HR, decreased BP, fever
* Fluctuating levels of consciousness
* Short attention span
* Disturbed sleepwake cycle; hour-to-hour variation
* Marked early psychomotor changes
How does dementia compare with delirium?
Dementia
* Insidious onset with unknown date
* Slow, gradual, progressive decline
* Generally irreversible
* Disorientation late in illness
* Slight day-to-day variation
* Less prominent physiological changes
* Consciousness clouded only in late stage
* Normal attention span
* Disturbed sleepwake cycle; daynight
* Psychomotor changes late in illness
Delirium
* Abrupt, precise onset, known date
* Acute illness, lasting days or weeks
* Usually reversible
* Disorientation early in illness
* Variable, hour by hour
* Prominent physiological changes; increased HR, decreased BP, fever
* Fluctuating levels of consciousness
* Short attention span
* Disturbed sleepwake cycle; hour-to-hour variation
* Marked early psychomotor changes
How does dementia compare with delirium?
Dementia
* Insidious onset with unknown date
* Slow, gradual, progressive decline
* Generally irreversible
* Disorientation late in illness
* Slight day-to-day variation
* Less prominent physiological changes
* Consciousness clouded only in late stage
* Normal attention span
* Disturbed sleepwake cycle; daynight
* Psychomotor changes late in illness
Depression
* Abrupt onset
* History of depression
* Highlights disabilities
* ’Don’t know’ answers
* Diurnal variation in mood
* Fluctuating cognitive loss
* Tries less hard to perform and gets distressed by losses
* Short- and long-term memory loss
* Depressed mood coincides with memory loss
* Associated with anxiety
How does depression compare with dementia?
Dementia
* Insidious onset
* No psychiatric history
* Conceals disability
* Near-miss answers
* Mood fluctuation day to day
* Stable cognitive loss
* Tries hard to perform but is unconcerned by losses
* Short-term memory loss
* Memory loss occurs first
* Associated with a decline in social function
How do you clinically assess dementia?
- History and collateral
- Risk assessment
- Cognitive testing – MMSE/MOCA
- Physical and bloods
- Neuroimaging - single photon emission computerised tomography (SPECT)
- Follow up – PDS for up to 1 year
- Consider care needs/other supports
What are the key features of Dementia with Lewy Bodies?
- Dementia. Amnesia not prominent.
- Deficits of attention
- frontal executive
- visuospatial.
- Two = probable, One = possible
a. Fluctuation - marked, important feature
b. Visual hallucinations
c. Parkinsonism - Suggestive - REM sleep disorder, severe antipsych sensitivity, abnormal DAT scan
- Supported by falls, syncope, loss of consciousness, other psychiatric symptoms, autonomic dysfunction, scans
- Dx less likely if stroke disease or other brain/systemic illness.
The features of Dementia with Lewy Bodies is;
- Dementia. Amnesia not prominent.
Deficits of attention, frontal executive, visuospatial.
- Two = probable, One = possible
a. Fluctuation - marked, important feature
b. Visual hallucinations
c. Parkinsonism
Which medications must you NEVER give patients with Dementia with Lewy Bodies?
Anti-psychotic medications!!!
What are the key features of frontotemporal dementia?
- Behavioural disorder – personality change
- Speech disorder -
- altered output
- stereotypy
- echolalia
- perseveration
- mutism
- Neuropsychology -
- frontal dysexecutive syndrome.
- Memory, praxis and visuospatial function not severely impaired
- frontal dysexecutive syndrome.
- Neuroimaging - abnormalities in frontotemporal lobes
- Neurological signs commonly absent early;
- parkinsonism later;
- MND in a few;
- autonomic;
- incontinence;
- primitive reflexes
What drugs are used to treat dementia?
Acetylcholinesterase Inhibitors (AChEI) for mild to moderate SDAT
- Donepezil
- Rivastigmine
- Galantamine
- Rivastigmine - (used especially in LBD)
NMDA receptor antagonist
- Memantine
The drugs used to treat dementia are;
Acetylcholinesterase Inhibitors (AChEI) for mild to moderate SDAT
- Donepezil
- Rivastigmine
- Galantamine
- Rivastigmine - (used especially in LBD)
NMDA receptor antagonist
- Memantine
What are the side effects of cholinesterase inhibitors?
–Nausea, vomiting, diarrhoea
–Fatigue, insomnia
–Muscle cramps
–Headaches, dizziness
The drugs used to treat dementia are;
Acetylcholinesterase Inhibitors (AChEI) for mild to moderate SDAT
- Donepezil
- Rivastigmine
- Galantamine
- Rivastigmine - (used especially in LBD)
NMDA receptor antagonist
- Memantine
What are some other psychotropics used?
- Non pharmacological measures first
- Most are used off licence
- Antipsychotics (eg. risperidone, quetiapine, amisulpride)
- Antidepressants (eg. Mirtazapine - quite sedative), sertraline)
- Anxiolytics (eg. lorazepam)
- Hypnotics (eg. zolpidem, zopiclone, clonazepam)
- Anticonvulsants (eg. valproate, carbamazepine)
What 5 things are required for capacity?
R U MAC?
R- retain memory
U- understand
M- make
A- act
C- communicate
What 5 things are required for capacity?
R U MAC?
R- retain memory
U- understand
M- make
A- act
C- communicate
Abilities relevant to competence
- Understanding
- Manipulating
- Approaching the situation and its consequences
- Communicating choices
Power of attorney grants someone else authority to make decisions over what?
- Finance
- Usually easier to retain capacity re granting this than for welfare
- Welfare
- Bigger issues
- Solicitor assesses capacity
- POA to act in best interests
- Are the powers being misused?
- Revocation of power of attorney
- Public Guardian’s Office
