Old age psychiatry

Question 1

what are the most common mental health problems in the elderly?

Answer 1

• Dementia
• Delirium
• Depression
• Schizophrenia like psychosis
• Anxiety
• Alcohol misuse

Question 2

Stages of dementia

Answer 2

1-	Early stage
•	Generally symptom free 
•	Some cognitive impairment 
2-	Mild to moderate stage 
•	Decline in cognitive impairment 
•	Functional decline 
•	Behavioural symptoms 
3-	Severe stage 
•	Complete loss of functional ability 
•	Need to be institutionalized

Question 3

How to assess a patient with dementia

Answer 3

ABCD

A- Activities of daily living
B- Behavioural and psychiatric symptoms of dementia
C- Cognitive impairment
D- Decline

-Need a collateral history
-Flexible cognitive testing:
• Memory + one or more of:
o Dysphasia (expressive/ receptive)
o Dyspraxia- motor skill problem
o Dysgnosia (not recognizing objects)
o Dyexecutive functioning
• Functional decline ADLs

MMSE score

Question 4

Main features of dementia

Answer 4

• insidious onset with unknown date
• slow, gradual, progressive
• generally irreversible
• disorientation in late illness
• day to day variation
• few physiological changes
• consciousness clouded in LATE stage
• normal attention span
• disturbed sleep wake cycle ( day to night)
• Psychomotor changes in LATE Illness
• Short term memory loss
• Memory loss early on
• Conceals disability
• Mood fluctuation day to day

Question 5

Differences with delirium

Answer 5

• Abrupt, precise onset, known date
• Acute illness
• Usually reversible
• Disorientation early in illness
• Variable, hour by hour
• Prominent physiological changes
• Disturbed sleep-¬wake cycle hour-to-hour variation
• Marked early psychomotor changes

Question 6

Differences with depression

Answer 6

• Abrupt onset
• History of depression
• Highlights disabilities
• ’Don’t know’ answers
• Diurnal variation in mood
• Fluctuating cognitive loss
• Tries less hard to perform
  and gets distressed by losses
• Short- and long-term memory loss
• Depressed mood coincides with
  memory loss
• Associated with anxiety

Question 7

Treatment for dementia

Answer 7

Acetylcholinesterase Inhibitors (AChI) for mild to moderate AD
◦donepezil, rivastigmine, galantamine
Memantine for moderate to severe AD
Antipsychotics (eg. risperidone, quetiapine, amisulpride)
Antidepressants (eg. mirtazapine, sertraline)
Anxiolytics (eg. lorazepam)
Hypnotics (eg. zolpidem, zopiclone, clonazepam)
Anticonvulsants (eg. valproate, carbamazepine)

Question 8

How do AchI work?

Answer 8

• Improve cognitive function
• Slow down decline
• Improve non cognitive symptoms e.g. ADL

Question 9

Aetiology Depression in the elderly?

Answer 9

1-	Loss of 
o	Health 
o	Wealth 
o	Spouse
o	Work 
o	Home 
2-	Genetic

Question 10

what is normal and what is not normal when dealing with grief?

Answer 10

Normal 
◦Alarm
◦Numbness
◦Pining – illusions or hallucinations may occur
◦Depression
◦Recovery and reorganisation

Abnormal 
◦Persisted beyond 2 months
◦Guilt
◦Thoughts of death
◦Worthlessness
◦Psychomotor retardation
◦Prolonged and marked functional impairment
◦Psychosis

Question 11

Suicide in the elderly epidemiology

Answer 11

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

Question 12

Late onset schizophrenia like-psychosis aetiology

Answer 12

• sensory loss
• social isolation
• minor genetic abnormalities

Question 13

what to think about in elderly care?

Answer 13

• Capacity

- Fitness to drive