Old Age Psychiatry

Question 1

How is dementia characterised?

Answer 1

Clinical syndrome with following characteristics:
Activities of daily living
Behavioural and psychiatric symptoms of dementia (BPSD)
Cognitive impairment
Decline (symptoms must be worsening for dementia diagnosis)

Question 2

How is cognitive impairment in dementia defined?

Answer 2

Memory loss plus at least one of the following:
•Dysphasia
•Dyspraxia (inability to carry out motor skills)
•Dysgnosia (not recognising objects)
•Dysexecutive functioning (loss of higher functions, inability to plan/organise themselves etc)

Question 3

What are the most common BPSDs?

Answer 3

Psychosis
Depression
Altered circadian rhythm
Agitation
Anxiety

Question 4

What are the causes of dementia, from most to least common?

Answer 4

Alzheimers
Vascular
Mixed Alzheimer and vascular
Lewy body 
Other (frontotemporal, MS or huntingtons related dementia)

Question 5

What tests can be done in dementia?

Answer 5

A mini mental state exam (MMSE)
Montreal cognitive assessment (MOCA)
Brain imaging- MRI is gold standard but is often avoided due to them being expensive, their longer wait time and are less well tolerated. CT or SPECT are used more commonly

Question 6

What are the characteristics of dementia with Lewy bodies?

Answer 6

1. Dementia with amnesia not prominent
2. Fluctuation, visual hallucinations and/or parkinsonism (2= probable, 1=possible)
3. REM sleep disorder, severe antipsychotic sensitivity, abnormal DAT scan (all suggestive)
4. Diagnosis supported by syncope, falls, loss of consciousness, other psychiatric symptoms, autonomic dysfunction and scans
5. Diagnosis less likely if stroke or other brain/systemic illness present

Question 7

What scan should be used in dementia with lewy bodies/

Answer 7

DATscan- 85% specific

Question 8

What are the symptoms of frontotemporal dementia?

Answer 8

Behavioural disorder- personality change
Can be early onset
Early emotional blunting
Speech disorder
Frontal dysexecutive syndrome- memory, praxis and visuospatial function not severely impaired
Neuroimaging- abnormalities in frontotemporal lobes
Neurological signs often absent early in disease, Parkinsonism often present later on

Question 9

What are the possible drug treatments for dementia?

Answer 9

• 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 10

What are the pros of cholinesterase inhibitors in dementia?

Answer 10

They improve cognitive function, slow decline and improve non-cognitive symptoms

Question 11

What are the side effects of cholinesterase inhibitors?

Answer 11

Nausea, vomiting, diarrhoea
Fatigue, insomnia
Muscle cramps
Headaches and dizziness
Syncope
Breathing problems

Question 12

How does presentation of depression vary in the elderly?

Answer 12

Depressed mood and expressed suicidal intent being less common but insomnia, hypochondriasis, completed suicide and agitation being more common

Question 13

What are the possible causes of depression in the elderly?

Answer 13

Loss of health, wealth, spouse, work and home