Old Age Psychiatry Flashcards
What are the three big ‘D’s in the hospital?
Dementia
Delirium
Depression
What age are the majority of people in hospital?
2/3rd hospital beds filled by elderly patients?
How do you diagnose dementia?
Clinically using criteria, flexible cognitive testing and a collateral history!
What is the ABCD of dementia?
A = ADL affected B = BPSD (behavioural and psychiatric symptoms of dementia) C = cognitive impairment D = decline
What are the features of dementia required for diagnosis?
Amnesia/dysmnesia (foregetfulness) + 1 or more of: Dyphasia (expressive/receptive) Dysgnosia Dsypraxia Dysexecutive function
AND FUNCTIONAL DECLINE (ADLs)
What is expressive dysphasia?
Difficulty finding the right word, but can understand what you are saying
E.g. nominal aphasia = difficulty finding the names of things
What is receptive aphasia?
Difficulty understanding
What is dyspraxia?
Difficulty carrying out motor skills despite an intact nervous system
What is dysgnosia?
Not recognising things/people etc. (can be any of 5 senses)
What is dysexecutive functioning?
Problems with sequencing, planning, mood, sexuality, personality,
FRONTAL pathology
In dementia there is classically a long/short progression
Long
What correlates with ability to perform daily activities?
MMSE score
Describe the difference between instrumental activities of daily living and basic activities of daily living
BADL = basic things you do before going to bed/after getting up
IADL = using computers, keeping to appointments etc.
What neuropsychotic disturbances are common in dementia?
Psychosis (esp. paranoid ideas relating to theft, plotting etc.) Depression Altered circadian rhythms Agitation Anxiety
What is the nature of the BPSD in terms of when they are present?
Relapsing, remitting nature
What is the most common cause of dementia?
Alzhiemers disease
How do you distinguish between Parkinson’s and Lewy body dementia?
Parkinson’s - motor symptoms come on first (1y before cognitive problems) - vice versa for Lewy body
Commonly get hallucinations in lewy body which you don’t get as often in Parkinsons
What are the three stages of dementia progression?
Early - tends to be unnoticed
Mild-moderate - progressive decline in functional ability/cognition
Severe - requires institutionalisation
What is the pathway of diagnosis/treatment etc. for dementia?
Brought to primary care –> history, collateral history, MSE, physicals and blood, cognitive assessment –> if suspicion of dementia –> exclude other causes of dementia, delirium and depression –> refer
What happens after specialist referral?
Confirmation of diagnosis
Brain scanning and neuropsychology
Management and counselling
What two tools can you use to assess cognition?
MMSE and MOCA
What components of cognition does MOCA look at?
Executive/visuospatial Naming Memory Attention Language Abstraction Delayed recall Orientation
What brainscans can you do in dementia?
CT
SPECT (functional scanning)
MRI best if suspect vascular dementia
What would you see in the CT of someone with AD?
Temporal lobe and hippocampal atrophy
What should changes in personality, apathy and headache raise your suspicion of?
Space occupying lesion in frontal cortex
What will you see on a SPECT of someone with frontotemporal dementia?
Frontal hypoperfusion
What will you see on a SPECT of someone with AD?
Temporal and parietal and occipital hypoperfusion
What things will you tend to see in lewy body dementia?
Amnesia not that prominent (deficits of attention, frontal executive, visuospatial) 1 = possible, 2 = probable Fluctuation Visual hallucinations Parkinsonism
Suggestive: REM sleep disorder, severe antipsych sensitivity, abnormal DATscan, restless, kicking out
What may support a diagnosis of lewy body dementia?
Falls, syncope, loss of consciousness, psychiatric symptoms, autonomic dysfunction/instability
What does a DATScan do?
Lights up dopamine in the brain
What does a DATscan in a normal person look like?
Normal re-uptake of dopamine transporter in caudate nucleus and putamen
What does a DATscan in someone with lewy body dementia look like?
Re-uptake in putamen is reduced –> small dot of uptake
A patient gradually stopping caring about his appearance and personal hygiene with a clear change in personality (apathy, withdrawn) is likely to indicate what?
Frontotemporal dementia
What does a CT of someone with frontotemporal dementia’s brain look like?
Gryi thinner and sulci bigger in frontotemporal region
What is Pick’s disease?
Classic FT dementia
What features are consistent with FT dementia?
Personality change (apathy) Can be early onset Early emotional blunting Speech disorder (echolalia, mutism, altered output etc.) Frontal dysexecutive function
Why is memory often spared in vascular dementia?
Due to preservation of grey mater
What features are consistent with vascular dementia?
Step wise decline, deterioration in executive function, mood changes (e.g. irritability)
Depends where is affected really
How do you treat mild-moderate AD, LBD, FT dementia?
Acetylcholinesterase inhibitors (e.g. donepezil, galantamine, rivastigmine)
How do you treat moderate-severe AD?
Memantine (can use combo with AChI)
What other drugs may be used in treating AD/FT dementia?
Antipsychotics (amisulfride, quetiapine, risperidone) - increases risk of stroke!!
Antidepressants (e.g. mirtazapine, sertraline)
Anxiolytics, e.g. lorazepam
Hypnotics (e.g. clonazepam) but increase fall risk
Anticonvulsants
What should you definitely not use in LDB?
Antipsychotics - make hallucinations worse
What are side effects of cholinesterase inhibitors?
N/V, diarrhoea, fatigue, insomnia, muscle cramps, dizziness, headaches, syncope, breathing problems
More elderly females/males are depressed
Males
What are the precipitating factors for depression in the elderly?
Loneliness Widowed Ill health Chronic pain Recent life events
What is late-onset schizophrenia like psychosis?
Tends to be elderly women, who are cognitively intact but present with paranoid delusions, ideas of reference or of being observed
Do well on antipsychotics
What is the rules governing driving and dementia?
Must inform DVLA
Yearly license
Those with poor short term memory, disorientation or lack of insight are not fit to drive
What pathology characterises AD?
Beta-amyloid plaques
Tangles
Macroscopically - brain atrophy, gryri narrow and sulci and ventricles enlarge and hippocampus atrophies
What features are characteristic of AD?
Short term memory loss Loss of motor skills Language problems Long term memory loss Disorientation
What is the pathology associated with FT dementia?
Tangles in the frontal and temporal lobes
What characteristics are most associated with FT dementia?
Personality and behaviour changes
Aphasia
Memory, concentration, ability to learn new things
IMPULSIVE, INAPPROPRIATE BEHAVIOUR
What is vascular dementia?
Multi-infarct dementia: progressive loss of brain function due to long term hypoperfusion of the brain (typically due to small strokes)
What risk factors are associated with vascular dementia?
HTN, smoking, vascular disease, previous stroke/TIA, AF, DM, hyperlipidaemia, obesity
What are lewy bodies?
Protein build up inside neurons
What is the function of the substantia nigra?
Initiating movements
What kinds of neurons are in the substantia nigra?
Dopaminergic neurons
What three things would ring alarm bells for lewy body dementia?
Dementia, parkinsonism, hallucinations
