Old Age Psychiatry Flashcards
Which age cut off is classified as ‘elderly?’
> 65 years
Give members of the MDT who will be typically involved in the care of an elderly person? (6 or more)
Care of the elderly doctors Specialist nurses Social workers Occupational therapists Physiotherapists Psychologists Psychiatrists
Which contributing factors predispose depression in the elderly?
Bereavement, social isolation, poverty, physical illness and chronic pain
Which symptoms of depression may be exaggerated in the elderly?
o Physical symptoms (e.g. constipation)
o Agitation or retardation
o Memory problems (and pseudodementia)
Outline the management of depression in the elderly
o Problem-solving, increasing socialisation and day-time activities
o Psychological therapies (e.g. CBT, psychodynamic therapy, group therapy, family therapy, couple therapy)
o Antidepressants: SSRIs are first line
o ECT: consider if life-threatening or psychotic
Which side effect of SSRIs do you need to be particularly wary of in elderly patients?
Hyponatraemia
Outline the management of anxiety disorders
o CBT
o SSRIs may be helpful
Psychosis: give the risk factors for late onset schizophrenia and outline its management
o More common in isolated women
o Sensory deficits are a risk factor
o Positive symptoms are more prominent than negative
Management:
• Reduction of sensory impairment
• Exclusion of organic cause or LBD
• Low-dose antipsychotics
What is most important to assess in a patient with dementia?
• Effect of dementia on ADLs (activities of daily living) is an important part of the assessment
Examples of ADLs Financial management Using the toilet Washing, dressing, grooming Shopping Cooking House work Mobilising/transfers/stairs
Give causes of a low MMSE score
o Dementia o Delirium o Most psychiatric illnesses (e.g. depression, anxiety, psychosis) o Learning disability o Sensory impairment o Language barrier
Outline the general clinical features of dementia
Forgetfulness, mild mistakes in daily activities (e.g muddling up appointments, misplacing items etc.)
Disorientation
Mood and personality affected
Anxiety or depression may occur early
Wandering, sleep disturbance, delusions/hallucinations, shouting, inappropriate behaviour and aggression can occur
Outline the risk factors for Alzheimer’s disease (AD)
- Age
- Genetics (presenilin 1, presenilin 2, beta-amyloid precursor protein, apolipoprotein E4)
- Vascular risk factors
- Low IQ
- Head injury
Outline the key aspects of AD pathology
- Atrophy due to neuronal loss (hippocampus is affected early)
- Plaque formation - APP is abnormally cleaved into beta-amyloid which aggregates in insoluble clumps
- Intracellular neurofibriliary tangles made up of hyperphosphorylated tau proteins kill neurones
- Cholinergic loss (cholinergic pathways are most affected)
What are the 4A’s of the clinical presentation of AD?
- Amnesia: recent memories are lost first, disorientation occurs early
- Aphasia: word-finding problems occur, speech can become muddled
- Agnosia: recognise problems (e.g. faces)
- Apraxia: inability to carry out skilled tasks despite normal motor function (e.g. dressing)
Outline the key aspects of vascular dementia (VD) pathology
o Caused by infarcts due to thromboemboli or atherosclerosis
o Risk factors are the same as for stroke (male sex, smoking, hypertension, hypercholesterolaemia, diabetes, atrial fibrillation)
Outline the clinical presentation of VD
- Stepwise progression
- Each step is a sudden deterioration
- Several tiny infarcts may cause a smoother, more subtle degeneration
- Symptoms are dependent on site of infarct (presentation can be patchy)
Outline the key aspects of dementia with lewy bodies (DLB)
o Lewy bodies are eosinophilic intracytoplasmic neuronal structures consisting of alpha-synuclein and ubiquitin
o In DLB they are seen in the cyngulate gyrus and neocortex
(In Parkinson’s disease, Lewy bodies are found in the brainstem)
Outline the clinical presentation of DLB
- Fluctuating confusion with marked variation in levels of alertness
- Vivid visual hallucinations (often people or animals)
- Spontaneous parkinsonian sings (may present late)
In terms of order of symptoms: how does DLB differ from Parkinson’s disease
PD: Dementia occurs after parkinsonian symptoms
DLB: Dementia occurs before parkinsonian symptoms
What must you not prescribe in a patient with DLB?
Do NOT prescribe antipsychotics (e.g. haloperidol)
o Extreme antipsychotic sensitivity in DLB can result in DEATH
Give some differentials for dementia
• Delirium
o Presents suddenly with altered or clouded consciousness
o Losing touch with surroundings
o May be evidence of underlying physical problems
o Symptoms resolve once underlying cause is treated
• Reversible Dementias
o Presents with cognitive impairment that may resolve if treated
E.g: Brain: subdural haematoma, SOL, normal pressure hydrocephalus
Endocrine: hypothyroidism, hyperparathyroidism, Addison’s disease, Cushing’s syndrome
• Pseudodementia
o Memory problems in severe depression
o Low mood precedes cognitive problems
Outline the key investigations for dementia
• Physical examination and basic observations • Blood tests o FBC (infection/anaemia) o U&Es (dehydration/renal failure/hyponatraemia) o Glucose o TFTs (hypothyroidism) o LFTs (may suggest alcohol abuse) o B12 and folate o Calcium levels o VDRL (neurosyphilis)
• MMSE
• Collateral history
• Septic screen: MSU, CXR, blood cultures, wound swabs, sputum/stool samples (dependant on symptoms)
• CT or MRI head if:
o Unusual presentation/neurological signs
o First onset of psychotic symptoms later in life
o Planning to start anti-dementia medication
Outline the management of dementia in the following domains: Adaptations for patients, social support, support carers
• Adaptations for Patients, examples:
o Always carry ID, address and contact number in case they get lost
o Dossett boxes/blister packs to aid medication compliance
o Change gas to electricity
o Reality orientation (visible clocks, calendars)
• Social Support
o Personal care, meal preparation and medication prompting
o Day centres provide enjoyable daytime activities and social contact
• Support Carers o Emotional support o Educate about dementia o Train to manage common problems o Provide respite care
Outline the management of dementia in the following domains: Optimise physical health, psychotropic medications
Optimise Physical Health:
o Treat sensory impairment (hearing aids, glasses)
o Exclude superimposed delirium
o Treat underlying risk factors (e.g hypertension)
o Review all medication
• Psychotropic Medications
o Start doses low and increase slowly with any medication used
o Treat comorbid psychiatric illness (e.g. depression)
o Acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine)
• Can cause symptomatic relief
• Has no effect on the progression of dementia
