Old Age Psychiatry Flashcards
How does the prevalence of mental health disorders differ in community to hospital?
- Depression, dementia, delirium, anxiety and alcohol higher in hospital than community
- Schizophrenia is roughly the same in hospital and community
How does the prevalence of dementia differ by age group and gender?
- Increases with age
- Women surpass men between 75-79 years old
What is the ABCD of dementia as a clinical syndrome?
- Activities of daily living
- Behavioural and psychiatric symptoms of dementia (BPSD)
- Cognitive impairment
- Decline
What are the cognitive features of dementia?
Memory (dysmnesia) plus one or more
- Dysphasia (expressive or receptive)
- Dyspraxia
- Dysgnosia
- Dysexecutive functioning
Functional declines of ADL
What do MMSE scores correlate to in dementia?
Ability to perform daily activities
What neuropsychiatric disturbance can be present in dementia?
- Psychosis
- Depression
- Altered circadian rhythm
- Agitation
- Anxiety
Dementia vs Delirium
Onset
Dementia
-Insidious with unknown date
Delirium
-Abrupt, precise, known date
Dementia vs Delirium
Decline
Dementia
-Slow, gradual, progressive
Delirium
-Acute illness lasting days or weeks
Dementia vs Delirium
Reversibility
Dementia
-Generally irreversible
Delirium
-Usually reversible
Dementia vs Delirium
Disorientation
Dementia
-Late in illness
Delirium
-Early in illness
Dementia vs Delirium
Variability
Dementia
-Slight day to day variation
Delirium
-Variable, hour by hour
Dementia vs Delirium
Physiological changes
Dementia
-Less prominent changes
Delirium
-Prominent
Dementia vs Delirium
Consciousness
Dementia
-Clouded only in the late stage
Delirium
-Fluctuating levels
Dementia vs Delirium
Attention span
Dementia
-Normal
Delirium
-Short
Dementia vs Delirium
Sleepwake cycle
Dementia
-Disturbed, daynight
Delirium
-Disturbed, hour to hour variation
Dementia vs Delirium
Psychomotor changes
Dementia
-Late in illness
Delirium
-Marked early changes
Dementia vs Depression
Onset
Dementia
-Insidious onset
Depression
-Abrupt onset
Dementia vs Depression
Psychiatric history
Dementia
-None
Depression
-History of depression
Dementia vs Depression
Disability
Dementia
-Conceals disability
Depression
-Highlights disability
Dementia vs Depression
Answers
Dementia
-Near-miss
Depression
-Don’t know
Dementia vs Depression
Mood
Dementia
-Fluctuates day to day
Depression
-Diurnal variation
Dementia vs Depression
Cognitive loss
Dementia
-Stable cognitive loss
Depression
-Fluctuating cognitive loss
Dementia vs Depression
Concern about losses
Dementia
-Tries hard to perform but is unconcerned by losses
Depression
-Tries less hard to perform and gets distressed by losses
Dementia vs Depression
Memory loss
Dementia
-Short term
Depression
-Short and long term
Dementia vs Depression
Memory loss occurrence
Dementia
-Occurs first
Depression
-Depressed mood coincides with memory loss
Dementia vs Depression
Associated with…
Dementia
Decline in social -function
Depression
-Anxiety
What is dementia with Lewy Bodies?
- A type of dementia were amnesia is not prominent
- Deficits of attention, frontal executive and visuospatial
What are the criteria for dementia with Lewy Bodies?
Two= probable One=possible
- Fluctuation: marked, important feature
- Visual hallucinations
- Parkinsonism
What symptoms are suggestive of dementia with Lewy Bodies?
- REM sleep disorder
- Severe antipsych sensitivity
- Abnormal DAT scan
What would support a diagnosis of dementia with Lewy Bodies?
- Falls
- Syncope
- LoC
- Other psychiatric symptoms
- Autonomic dysfunction
- Scans
When is the diagnosis of dementia with Lewy Bodies less likely?
If stroke disease or other brain/systemic illness
How does frontotemporal dementia present?
- Behavioural disorder with personality change
- Can be early onset
- Early emotional blunting
- Speech disorder
- frontal dysexecutive syndrome
- Neurological signs commonly absent early, Parkinsonism later, MND in a few, autonomic, incontinence, primitive reflexes
What is seen on neuroimaging of frontotemporal dementia?
Abnormalities in frontotemporal lobes
What drug treatment can be used in dementia?
- Acetylchholinesterase inhibitors for mild to moderate SDAT (donepezil, rivastigmine, galantamine)
- Memantine for moderate to severe SDAT
- Antipsychotics (eg. risperidone, quetiapine, amisulpride)
- Antidepressants (eg. mirtazapine, sertraline)
- Anxiolytics (eg. lorazepam)
- Hypnotics (eg. zolpidem, zopiclone, clonazepam)
- Anticonvulsants (eg. valproate, carbamazepine)
What impact do cholinesterase inhibitors have on dementia?
- Improve cognitive function
- Slow decline
- Improve non cognitive symptoms including ADL, longer stay at home and reduced carer stress
- Does not stop disease progression
What are the possible side effects of cholinesterase inhibitors?
- Nausea, vomiting, diarrhoea
- Fatigue, insomnia
- Muscle cramps
- Headaches, dizziness
- Syncope
- Breathing problems
Why is there controversy in the use od neuroleptics?
- Efficacy
- SE including death
- Are you treating the patient or the carers?
How are neuroleptics used?
- Start low and go slow
- Review and stop
- Discuss the risks
How is dementia dealt with in care homes?
- 3/4 of care home residents have dementia
- Full of BPSD
- Psychosocial interventions recommended but medication often has to be relied upon
- Care inspectorate regulates services
How can dementia or organic brain syndrome affect your fitness to drive?
- Notify DVLA at diagnosis
- If early dementia license may be yearly
- “Those with poor short term memory, disorientation or lack of insight should almost certainly not drive”
What are the 5 components of capacity?
Essentially can they
- Act
- Make
- Communicate
- Understand
- Retain memory
on decisions
What abilities does a power of attorney have?
- Finance: usually easier to retain capacity re granting this than for welfare
- Welfare: big issues re powers to have you reside
What is guardianship?
- Person lack capacity to grant POA
- Can deal with finance and welfare
- Require medical certificate from GP and psychiatrist
Apart from dementia, what other mental health issues are present in the elderly community?
- Depressive symptoms and illness
- Anxiety disorders
- Mania
- Schizophrenia
- Late onset schizophrenia like psychosis
- Alcohol problems
- Suicide
- Medicolegal matters
What is the prevalence of depression?
- 15% of symptoms in community
- 3% illness
- F:M 1.5:1
- 20-30% in residential care
What are the clinical features of depression?
Less
- Depressed mood
- Expressed suicidal wishes
More
- Insomnia
- Hypochondriasis
- Suicide
- Agitation
What is the aetiology of depression?
- Loss of health, wealth, spouse, work and home
- Genetics
How is depression managed?
- Antidepressants (NB Tricyclic side effects)
- Cognitive-behavioural therapy
- ECT in severe cases need for prophylaxis
- Most community cases not treated
What is the prognosis for depression?
- Mortality x2
- 25% chronic
- Better with treatment
What are normal reactions to bereavement?
- Alarm
- Numbness
- Pining – illusions or hallucinations may occur
- Depression
- Recovery and reorganisation
What are considered abnormal reactions to bereavement?
- Persisted beyond 2 months
- Guilt
- Thoughts of death
- Worthlessness
- Psychomotor retardation
- Prolonged and marked functional impairment
- Psychosis
What is the prevalence of suicide in the elderly?
- Same rate as for under 25 age group
- Half the rate of other age groups
- Males more than females
- Most are depressed
- DSH is rare in the elderly
Why do some elderly people consider suicide?
- Lonely
- Widowed
- Ill health
- Chronic pain
- Recent life events
- Few see psychiatrist
What is the prevalence of late onset schizophrenia?
Up to 10% of psychiatric admission in old age
What are the clinical features of late onset schizophrenia?
Spectrum from circumscribed persecutory delusions to full schizophrenia-like psychosis
What is the aetiology of late onset schizophrenia?
- Sensory loss
- Social isolation
- Genetic ?minor abnormaliteis
How is late onset schizophrenia managed?
- Often needs compulsory admission
- Neuroleptics
- Increase social contact
What is the prognosis of late onset schizophrenia?
- May fail to regain insight
- High relapse if stop neuroleptics
What is the aetiology of dementia?
- Alzheimer’s
- Vascular dementia
- Mixed Alzheimer’s and vascular
- Lewy Body dementia
- Other causes
What is the course of dementia?
- Symptoms
- Diagnosis
- Loss of functional independence
- Behavioural problems
- Nursing home placement
- Death
How is AD diagnosed in primary care?
- Case findings
- Clinical assessment (history. MSE, physical and bloods, cognitive assessment)
- Exclude differentials
- Specialist referral for confirmation, counselling, management and follow up
What is the clinical presentation of subcortical vascular dementia?
- The clinical presentation of subcortical vascular dementia is often one of gradual deterioration in executive function, as well as mood changes such as apathy or irritability.
- Memory is often relatively spared and reflects the preservation of cortical grey matter.
- The patient may additionally have neurological features such as falls, incontinence or seizures.
How do you avoid dementia?
You don’t really. Possible links to
- Choose your parents
- Activity
- Caffeine
- Alcohol
- HRT
- Statins
- Hypertension
- NSAIDs
- Good nutrition
- Fish oils
- Vitamins
