Old Age Psychiatry

Question 1

Which age cut off is classified as ‘elderly?’

Answer 1

> 65 years

Question 2

Give members of the MDT who will be typically involved in the care of an elderly person? (6 or more)

Answer 2

Care of the elderly doctors
Specialist nurses
Social workers
Occupational therapists
Physiotherapists
Psychologists
Psychiatrists

Question 3

Which contributing factors predispose depression in the elderly?

Answer 3

Bereavement, social isolation, poverty, physical illness and chronic pain

Question 4

Which symptoms of depression may be exaggerated in the elderly?

Answer 4

o Physical symptoms (e.g. constipation)
o Agitation or retardation
o Memory problems (and pseudodementia)

Question 5

Outline the management of depression in the elderly

Answer 5

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

Question 6

Which side effect of SSRIs do you need to be particularly wary of in elderly patients?

Answer 6

Hyponatraemia

Question 7

Outline the management of anxiety disorders

Answer 7

o CBT

o SSRIs may be helpful

Question 8

Psychosis: give the risk factors for late onset schizophrenia and outline its management

Answer 8

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

Question 9

What is most important to assess in a patient with dementia?

Answer 9

• 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

Question 10

Give causes of a low MMSE score

Answer 10

o	Dementia  
o	Delirium  
o	Most psychiatric illnesses (e.g. depression, anxiety, psychosis)  
o	Learning disability  
o	Sensory impairment  
o	Language barrier

Question 11

Outline the general clinical features of dementia

Answer 11

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

Question 12

Outline the risk factors for Alzheimer’s disease (AD)

Answer 12

• Age
• Genetics (presenilin 1, presenilin 2, beta-amyloid precursor protein, apolipoprotein E4)
• Vascular risk factors
• Low IQ
• Head injury

Question 13

Outline the key aspects of AD pathology

Answer 13

• 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)

Question 14

What are the 4A’s of the clinical presentation of AD?

Answer 14

• 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)

Question 15

Outline the key aspects of vascular dementia (VD) pathology

Answer 15

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)

Question 16

Outline the clinical presentation of VD

Answer 16

• 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)

Question 17

Outline the key aspects of dementia with lewy bodies (DLB)

Answer 17

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)

Question 18

Outline the clinical presentation of DLB

Answer 18

• Fluctuating confusion with marked variation in levels of alertness
• Vivid visual hallucinations (often people or animals)
• Spontaneous parkinsonian sings (may present late)

Question 19

In terms of order of symptoms: how does DLB differ from Parkinson’s disease

Answer 19

PD: Dementia occurs after parkinsonian symptoms
DLB: Dementia occurs before parkinsonian symptoms

Question 20

What must you not prescribe in a patient with DLB?

Answer 20

Do NOT prescribe antipsychotics (e.g. haloperidol)

o Extreme antipsychotic sensitivity in DLB can result in DEATH

Question 21

Give some differentials for dementia

Answer 21

• 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

Question 22

Outline the key investigations for dementia

Answer 22

•	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

Question 23

Outline the management of dementia in the following domains: Adaptations for patients, social support, support carers

Answer 23

• 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

Question 24

Outline the management of dementia in the following domains: Optimise physical health, psychotropic medications

Answer 24

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

Question 25

Which types of psychological therapies could be offered for dementia?

Answer 25

Behavioural approaches
• Identify and modify underlying triggers for difficult/risky behaviours (e.g. wandering may be due to disorientation, boredom or anxiety)

Reminiscence Therapy
• Talking about the old days enhances a sense of belonging and reinforced identity

Validation Therapy
• Reassure and validate the emotion behind what is said

Multisensory Therapy
• As dementia advances and speech is lost, it may be easier to respond to touch, music etc.

Cognitive Stimulation Therapy
• Memory training and re-learning

Question 26

What are the key aspects of prognosis in dementia?

Answer 26

• 2/3 of people with dementia live in their own home or with a carer
• People should be supported to stay in their homes for as long as possible
• Placement in a nursing home may be required