Old Age Psychiatry Flashcards
Prevalence of depression in the community and in hospital
12% community
29% hospital
Prevalence of delirium in the community and in hospital
1-2% community
20% hospital
Prevalence of dementia in the community and in hospital
5% community
31% hospital
Prevalence of anxiety disorders in the community and in hospital
3% community
8% hospital
Prevalence of alcohol misuse in the community and in hospital
2% community
3% hospital
Prevalence of schizophrenia in the community and in hospital
- 5% community
0. 4% hospital
At any one time, what percentage of hospital beds are occupied by older people?
66%
What is the ABCD of dementia?
A - Activities of daily living (ADLs)
B - Behavioural and psychiatric symptoms of dementia (BPSD)
C - Cognitive impairment
D - Decline in functioning
What do you need to diagnose dementia?
Collateral history
Flexible cognitive testing
What are the cognitive features of dementia?
Dysmnesia (memory)
Plus one or more of;
- dysphasia
- dyspraxia
- dysgnosia
- dysexecutive functioning
Functional decline
ADLs
What does MMSE score correlate with?
Ability to perform daily actives
Types of neuropsychiatric disturbance in dementia
Psychosis e.g. hallucinations, delusions, loss of insight Depression Altered circadian rhythms Agitation Anxiety
Differences between dementia and delirium
Dementia
- onset is insidious, unknown start date
- slow, gradual, progressive decline
- irreversible
- disorientation late in illness
- slight day-to-day variation
- less prominent physiological change
- consciousness clouded in late stage
- normal attention span
- disturbed sleep-wake cycle day to night variation
- psychomotor changes late in illness
Delirium onset is abrupt/precise onset
- acute illness
- reversible
- disorientation early in illness
- variable hour-by-hour, classically worse at night
- prominent physiological change
- fluctuating levels of consciousness
- shortened attention span
- disturbed sleep-wake cycle hour to hour variation
- marked early psychomotor changes
When would dementia have a step-wise progression?
With vascular cause
How does depression vary from dementia?
Depression Abrupt onset History of depression Highlights disabilities 'Don't know' answers Fluctuating cognitive loss Tries hard to perform and gets distressed by losses Short and long-term memory loss Depressed mood coincides with memory loss Associated with anxiety
Dementia Insidious onset No psych history Conceals disability Near-miss answers Mood fluctuation day to day Stable cognitive loss Treis hard to perform but is unconcerned by losses Short term memory loss Memory loss occurs first Associated with decline in social function
Why might it be difficult to differentiate between dementia and depression?
Depression can manifest as dementia, or the dementia syndrome of depression
Dementia can present with depressive symptoms in the early stage of the illness
Depression and dementia often co-exist
What percentage of individuals diagnosed with dementia will have co-existing depressive symptoms at some stage of the illness?
Up to 50%
Aetiology of dementia
Alzheimer's disease 50% Vascular dementia 25% Mixed Alzheimer's and vascular 15% Lewy body dementia 5% Other causes 5%
What are the stages of dementia?
Early
Mild-to-moderate
Severe
Differences between stages of dementia
In early stage, patient with generally remain symptom-free
As illness progresses, the extent of cognitive impairment becomes such that the patient and caregivers recognise that there is a problem
A progressive and insidious decline in cognition and functional ability marks the mild-to-moderate stage
Cognitive loss leads to functional decline and behavioural symptoms
During severe stages, functional ability is lost completely and institutionalisation is inevitable
What should be viewed as a viable treatment objective?
The ability to maintain function or cognitive capabilities for as long as possible
What is involved in the clinical assessment of a patient with dementia?
History and collateral Risk assessment Cognitive testing Physical examination Bloods Neuroimaging Follow up Consider care needs/other support
Presentation of Lewy body dementia
Dementia - amnesia not prominent
Deficits of attention, frontal executive and visuospatial
Two of the following = probable, 1 = possible
- fluctuation, marked, important feature
- visual hallucinations
- Parkinsonism
What is suggestive of Lewy body dementia?
REM sleep disorder
Severe antipsychotic sensitivity
Abnormal DAT scan
What is the diagnosis of Lewy body dementia supported by?
Falls Syncope Loss of consciousness Other psychiatric symptoms Autonomic dysfunction Scans
When is a diagnosis of Lewy body dementia less likely?
If stroke disease or other brain/systemic illness present
Clinical presentation of frontotemporal dementia
Behavioural disorder - personality change
Speech disorder - altered output, stereotypy, echolalia, perseveration, mutism
Neurological signs commonly absent in early stages - Parkinsonism occurs later, MND in a a few, autonomic features, incontinence, primitive reflexes
Neuropscyhology features of frontotemporal dementia
Frontal dysexecutive syndrome
Memory, praxis and visuospatial function not severely impaired
Neuroimaging features of frontotemporal dementia
Abnormalities in frontotemporal lobes - knife blade atrophy
Drug treatment of dementia
Acetylcholinesterase inhibitors for mild to moderate SDAT - donepezil, rivastigmine, galantamine
LBD - rivastigmine
Memantine for moderate-to-severe SDAT
Features of cholinesterase inhibitors in dementia treatment
Slow decline
Improve non-cognitive symptoms
Do not stop disease progression
Side effects of cholinesterase inhibitors
Nausea, vomiting, diarrhoea Fatigue Insomnia Muscle cramps Headaches, dizziness Bradycardia, syncope, gastric ulcer and respiratory problems
Other psychotropics used in dementia treatment
Non-pharmacological measures done first Most are used off-licence Antipsychotics e.g. risperidone, quetiapine Antidepressants e.g. mirtazapine Anxiolytics e.g. lorazepam Hypnotics e.g. zolpidem Anticonvulsants e.g. valproate
Neuroleptics use in dementia
Controversial - small effect size, side effects including cardiovascular SE and death Policy including covert pathway Reality - start low and go slow - review and stop - discuss risks
What number of residents in care homes have dementia?
3/4
When do the DVLA need to be notified of a diagnosis of dementia?
Notify at time of diagnosis
If early dementia, license may be yearly
Those with poor short-term memory, disorientation or lack of insight should not drive
Capacity involved abilities relevant to competence, what are these abilities?
Understanding
Manipulation
Appreciating the situation and its consequences
Communicating choices
What needs to be considered when determining whether an individual has capacity?
Can they;
- act
- make
- communicate
- understand
- retain memory of
medical treatment, hospitalisation etc.
Features of power of attorney
Can be power of attorney for finance or welfare
Solicitor assesses capacity
PoA to act in best interests of patient
Features of guardianship
Finance, welfare Lack of capacity to grant PoA Two medical certificates needed - GP and psychiatrist Detailed report from MHO - will it take into account family and those nominated in the application? - is it needed? - is it agreed? - who will be the guardian?
What percentage of older people have depressive symptoms?
15%
What percentage of older people have a depressive illness?
3%
Other disorders in old age psychiatry
Depressive symptoms Depressive illness Anxiety disorders - generalised anxiety - panic disorder - agoraphobia - PTSD Mania Schizophrenia Late onset schizophrenia-like psychosis Alcohol problems Suicidal ideation
Prevalence of depression in the community
15%
3% depressive illness
What percentage of people in residential care have depression?
20-30%
Clinical features of depression in the elderly
Less; depressed mood, expressed suicidal wishes
More; insomnia, hypochondriasis, suicide, agitation
Aetiology of depression in the elderly
Loss of - health, wealth, spouse, home, work
Genetic
Management of depression in the eldery
Antidepressants
CBT
ECT in severe cases
Prophylaxis need
Mortality of elderly people with depression
2 x that of those without depression
What percentage of depression in the elderly is chronic?
25%
Normal features of grief, mourning and bereavement
Alarm Numbness Pining - illusions or hallucinations may occur Depression Recovery and reorganisation
Abnormal features of grief, mourning and bereavement
Persisted beyond 2 months Guilt Thoughts of death Worthlessness Psychomotor retardation Prolonged and marked functional impairment Psychosis
Rate of suicide in the elderly
Same rate as for < 25 age group
Half the rate of other groups
M > F
Causes of suicide in the elderly
Most are depressed Loneliness Widowed Ill-health Chronic pain Recent life events
Prevalence of late-onset schizophrenia like psychosis
Up to 10% of psychiatric admissions in old age
Clinical features of late-onset schizophrenia-like psychosis
Spectrum from circumscribed persecutory delusions to full schizophrenia-like psychosis
Aetiology of late-onset schizophrenia-like psychosis
Sensory loss
Social isolation
Genetic - minor abnormalities
Management of late-onset schizophrenia-like psychosis
Often needs compulsory admission
Neuroleptics
Increase social contact
Prognosis of late-onset schizophrenia-like psychosis
May fail to regain insight
High relapse if neuroleptics are stopped
What percentage of older people experience improved cognitive function with abstinence from alcohol?
75%
Disorders caused by alcohol in the elderly
Alcohol dementia
Korsakoff’s psychosis
Alcohol hallucinosis
