Old Age Psychiatry Flashcards
Which mental health disorders are much more common in hospital than in the community?
Depression
Dementia
Delirium
Anxiety
Is dementia more prevalent in males or females?
Females
Does prevalence of dementia increase gradually with age?
Yes
Which age group has the highest prevalence of dementia?
95-99
In a general regional hospital, what is the percentage of beds occupied by elderly people?
66%
In what way can mental health disorders such as depression, delirium and dementia affect the length of a patients hospital stay?
Increased
How are survival rates affected if a patient has a mental health disorder such as a depresison, delirium or dementia?
Patients with delirium and dementia have the most reduced rate of survival
What is the ABCD of dementia?
A - Activities of Daily Living (ADL’s)
B - Behavioural and Psychiatric symptoms of dementia
C - Cognitive Impairment
D - Decline
What other information must be gathered when doing an assessment of a dementia patient?
1 - Collateral history
2 - Flexible cognitive testing
What are the cognitive features of dementia?
1) Memory impairment (dysmnesia) plus 1 or more of the following:
- Dysphasia (receptive or expressive)
- Dyspraxia (cannot carry out motor skills)
- Dysgnosia (not recognising objects)
- Dysexecutive function
2) Functional decline (cannot perform ADL’s)
How does MMSE score correlate with ability to perform ADL’s?
The higher the MMSE score means the patient can perform more complex ADL’s:
- MMSE < 15 means the patient may struggle with keeping appointments, using the phone
Lower MMSE scores (< 15) are correlated with greater difficulties in performing basic ADL’s
What are the signs of neuropsychiatric disturbance associated with dementia?
1 - Psychosis
2 - Depression
3 - Anxiety
4 - Agitation
5 - Altered circadian rhythms
How is Alzheimers disease diagnosed?
1) Case-finding (symptoms suggesting cognitive impairment)
IF YES, THEN MOVE ON TO 2)
2) Clinical assessment (History and collateral history, MSE, Physical exam and bloods, cognitive assessment)
IF FUNCTIONAL DECLINE AND COGNITIVE IMPAIRMENT DETECTED, THEN MOVE ON TO 3)
3) Exclude differential diagnosis (exclude delirium, depression)
IF ALZHEIMERS DISEASE DIAGNOSED, MOVE ONTO 4)
4) Specialist referral:
- Confirm diagnosis (brain scanning, neuropsychology)
- Management and symptomatic treatment
What psychiatric disorder is dementia often mistaken for?
Delirium
What are the key differences that differentiate dementia from delirium?
Onset:
Dementia = insidious, gradual
Delirium = Abrupt, precise
Progression:
Dementia = Gradual, progressive and non-reversible
Delirium = Rapid and usually reversible
Disorientation:
Dementia = Late in illness
Delirium = Early in illness
Physiological changes:
Dementia = Less prominent
Delirium = Prominent
What are the differences differentiating dementia from depression?
Onset:
Dementia = insidious
Depression = abrupt
PSH:
Dementia = None
Depression = History of depression
Mood fluctuation:
Dementia = Day to day fluctuation
Depression = Diurnal variation
Cognition:
Dementia = Stable cognitive loss
Depression = Fluctuating cognitive loss
What are some of the questions asked in an MMSE?
1 - What is the year? Date? Day of the week?
2 - Where are we now: Town? City? Hospital?
3 - Count backwards from 100 in steps of 7. Stop after 5 answers
4 - Ask the patient to name 2 simple objects
5 - Repeat a phrase said by the doctor (‘no ifs, ands, or buts’)
Apart from the MMSE, what other methods can be used to assess cognition?
Montreal Cognitive Assessment (MOCA)
Given the following information, what is the most likely diagnosis and should imaging be ordered and what type of imaging?
- 78 y.o. woman referred by GP with 3 year history of gradual and progressive deterioration in ‘memory’
- Cognition testing shows some dysmnesia and dysexecutive dysfunction
- Functional impairment (relies on daughter)
- No focal neurological signs
- No history of vascular disease or risk factors
Diagnosis = Alzheimers Dementia
Imaging - Coronal MRI to view atrophy of temporal lobes
What are the key differences between Alzheimers dementia and Dementia with Lewy Bodies?
Lewy-body features:
- Problems with problem solving & attention
- Problems with complex reasoning (executive dysfunction)
- Problems with moving (parkinsonism features)
Alzheimers features:
- Problems making new experiences into memories
How can a DAT scan be helpful in distinguishing between Alzheimers and Lewy-body dementia?
DAT Scan in Alzheimer Dementia - ‘Comma’ shape showing re-uptake of dopamine transporter (left image)
DAT Scan in Lewy-body Dementia - ‘Full-stop’ shape showing re-uptake of dopamine transporter (right image)
Where in the brain is dopamine re-uptake inhibited in Dementia with Lewy-bodies?
Putamen
Given the following information, what is the most likely diagnosis? What imaging would you order?
- 50 y.o. male
- Gradual change in behaviour over last 2 years (apathetic & withdrawn)
- Stopped taking care of his appearance and personal hygiene
- Used to be tidy but house now chaotic
Diagnosis - Frontotemporal dementia (caused by Pick’s disease)
Lew body dementia is a cross-over between which 2 conditions?
Parkinsons
Dementia
What type of dementia is more likely to present with cognition in tact, or cognition lost in a stepwise manner (with strokes)?
Vascular
What type of dementia is more likely to present with decline in cognition?
Alzheimers dementia
What are the key features of Frontotemporal dementia?
1 - Behavioural disorder (personailty change)
2 - Emotional blunting
3 - Speech disorder
4 - Neuroimaging shows abnormalities in frontotemporal lobes
What are the key clinical features of subcortical vascular dementia?
1 - Gradual deterioration in executive function
2 - Apathy & irritability
3 - Memory spared
4 - Neurological features such as falls, incontinence, seizures
What medications are used to treat mild to moderate Senile Dementia - Alzheimer type (SDAT) dementia?
Acetylcholinestersae Inhibitors
What drugs are used to treat moderate to severe Senile Dementia Alzheimer Type (SDAT)?
Memantine
What other classes of drugs can help with the treatment of dementia?
Antipsychotics
Antidepressants
Anxiolytics
Anticonvulsants
What aspects of dementia do cholinesterase inhibitors help improve?
1 - Cognition
2 - Slow down decline (do not stop disease progression)
3 - Improve ADL’s
4 - Increase likelihood of staying at home
What are the side-effects of cholinesterase inhibitors?
1 - Nausea, vomitting & diarrhoea
2 - Fatigue
3 - Insomnia
4 - Muscle cramps
What legal aspects of patient care must be considered when dealing with patients with dementia?
1 - Capacity
2 - Power of Attorney (finance, welfare)
3 - Guardianship
Apart from dementia, what are the other most prevalent psychiatric conditions of the elderly?
1 - Depression
2 - Anxiety
3 - Bipolar
4 - Schizophrenia
5 - Delirium
What questions must the doctor ask themselves when evaluating a patients capacity?
- Can they make a specific decision when required?
- Understand the information given to them to help them make a decision
- Can they retain the information given to them?
If a patient is diagnosed as having dementia or another organic brain syndrome, who needs to be made aware?
DVLA
What are the key aspects of investigating someone for suspected dementia?
1 - History (ADL’s, BPSD)
2 - Collateral history
3 - Flexible cognitive testing
4 - MSE
