Old age psychiatry Flashcards
Bipolar
usually known/primary (early onset)
secondary: middle-aged onset
later onset poor prognosis
first episode, no FHx = organic UPO (CVA, FTD)
depression prominent; mania ‘less’ - limited by physical frailty/illness
Mania Sx
elevated/expansive, irritable >1/52 or needing Ax
serious impact on life/function
3 more from:
restless, pressured speech/thought flight, disinhibited, reckless, sexual, sleep, self-esteem/grandeur
History
demographics
reason for referral
HPC: onset (Dates), non-cognitive symptoms, impact (fx/ADL)
PMH, PPH, RFs
FH, DH (incl. compliance and changes)
SH: drugs/alcohol, care package, driving
personal, forensic, pre-morbid, social circs
drugs affecting cognition
often ACH-related
e.g.
oxybutynin (for overactive bladder) amitriptyline (depression and anxiety)
MSE
- Appearance
- Behaviour
- Speech
- Mood
- Thought form
- Thought Content
- Thought Possession
- Perception
- Cognition
- Insight and Judgement
1. Appearance Distinctive features Clothing Posture/gait Grooming/hygiene Evidence of self-harm
2.Behaviour Eye contact Facial expression Psychomotor activity – motor activity related to mental processes (can be slowed or increased) Body language / gestures / mannerisms Level of arousal – calm / agitated / aggression Ability to follow requests Rapport / engagement
3.Speech
Rate of speech – pressured / slowed
Quantity of speech – minimal (e.g. only in response to questions) /excessive speech / complete absence of speech
Tone of speech – monotonous / tremulous
Volume of speech – loud / quiet
Fluency and rhythm of speech – articulate / clear / slurred
4 Mood (climate) and affect (weather) Mood; “How are you feeling?” “What is your current mood?” “Have you been feeling low/depressed/anxious lately?”
affect:
Sad/agitated/hostile
Euphoric/animated
Labile = quickly change states
- Thought Form
Speed – accelerated / racing / retarded
Flow/ coherence:
Linear – in a logical order
Incoherent – makes no logical sense
Circumstantial – lots of irrelevant/unnecessary details (not to the point)
Tangential – patient moves from one thought to the other that relate in some way but never gets to the point
Flight of ideas – there is an increased number of ideas, produced at a rapid pace
Perseveration – repetition of a particular response despite the absence/removal of the stimulus
- Thought content
Abnormal beliefs/ delusions
Obsessions – patient is aware they are irrational, but obsessive thoughts continue to enter their head
Overvalued ideas – e.g. the perception of weight in a patient with anorexia nervosa
Suicidal thoughts
Homicidal/violent thoughts
Examples of questions to screen for thought content abnormalities:
“What’s been on your mind recently?”
“Are you worried about anything?”
“Do things seem unreal to you?”
“Are there any thoughts you have a hard time getting out of your head?”
“Do you think anyone is trying to harm you?”
“Do you have any beliefs that aren’t shared by others you know?”
“Do you ever think about ending your life?”
“Have you ever felt your life was not worth living?”
“Have you ever attempted to end your life?”
“Do you ever think about harming other people?”
- Thought Possession
Thought insertion – belief that thoughts can be put into the patient’s mind
Thought withdrawal – belief that thoughts can be removed from patient’s mind
Thought broadcasting – belief that others can hear the patient’s thoughts
Examples of questions to screen for thought possession abnormalities:
“Do you think people can put ideas in your head?”
“Have you ever felt like people have removed/erased things/memories from your mind?”
“Do you ever feel like others can hear what you’re thinking?
8.Perception
Hallucinations – a sensory perception without any external stimulation of the relevant sense that the patient believes IS real (e.g. hears voices but no sound present)
Pseudo-hallucinations – the same as a hallucination but the patient is aware that it IS NOT real
Illusions – illusions are misinterpreted perception such as mistaking a shadow for a person (whereas a hallucination is a false perception)
Examples of questions to screen for perception abnormalities:
“Do you ever see, hear, smell, feel, or taste things that are not really there?”
“Did you think this was real at the time?”
“Do you still believe it was real?”
- Cognition
Basic testing:
Orientation (time/place/person)
Attention and concentration
Short-term memory
Detailed testing – Mini-mental state exam (MMSE/ACE-III)
10 Insight and Judgement
Insight
Is the patient able to recognise they have a problem or recognise what they’re experiencing is abnormal?
What does the patient think is the cause of the problem?
Does the patient want help with their problem?
Judgement
Assess the patient’s general problem-solving ability
Example question:
“What would you do if you could smell smoke in your house?”
HCE differences
settings: home visits (coping), OPD, care homes, IPD
memory issues (collateral)
comorbidities + polypharma (MH risk, SE/ADR)
pt perspective (significance and attribution)
suicide: more successful
Psychosis - features
abnromal mental state
altered perception (audio halls; persecutory reference dels- theft, mistreatment, poison)
behaviours change
formal thought disorder uncommon
present through others: concerned friends, police (calling), bizzare medical complaints
Psychosis - RF
female alone never married social isolation sensory impairment paranoid/schizoid personality
Psychosis - DDx (paranoia)
delirium
dementia
delusional disorder
organic: CVA, SDH, epilepsy, uraemia, hepatic enceph, hypoxia
Psychosis - Mx
assessment: home (calmer); history, collateral (?triggers, ?delusions, impact)
MSE + MOCA
risk assessment + insight
Ix: delirium and dementia screens
treatment:
therapeutic relationship
MDT: day centre, CPN, OT/PT, psych, community matron/CMHT
Treat comorbidities (sensory, pain, mobility)
APD (avoid poly, SE: EPSE, heart, sedation, falls, CVA in dementia); risperidone best/low dose depot
psychoeducation
social care package
