Old Age Psychiatry

Question 1

Psychosis in Old-Age (history)

Answer 1

• Clarify HPC (onset, duration)
• Explore auditory hallucinations (quality, content, number, 2nd/3rd person, commentary, commands, insight)
• Hallucinations in other modalities
• Delusional beliefs
• Thought interference and passivity phenomena
• Mood (mood, sleep, appetite, enjoyment)
• Memory
• Alcohol and drugs
• Risk
• Physical health (inc vision/hearing) and medications

Question 2

Psychosis in Old-Age (explanation)

Answer 2

• Clarify diagnosis
• Explain causes (family history, personality traits, hearing impairment)
• Explain treatment (inpatient/outpatient, MHA)
• Explain medication (mechanism, side-effects, duration 6m)
• Alternative treatments (CBT)
• Long-term management (CPN, OT/PT, discharge location)

Question 3

Stress/distress symptoms in dementia (history)

Answer 3

• Clarify HPC (duration, triggers, aggression)
• Psychiatric symptoms (diagnosis, follow-up, medications, mood, psychotic Sx)
• Physical symptoms (medical history, temperature, falls, pain, elimination)
• Environmental changes (space, people, activities)

Question 4

Stress/distress symptoms in dementia (explanation)

Answer 4

• Clarify concerns
• Explain treatment rationale (symptoms, risk, failed management)
• Explain side-effects (inc stroke risk, risk/benefit, low dose, duration)
• Alternative treatments (orientation, reminiscent therapy, art therapy, pet therapy, doll therapy, activities, family involvement)
• Questions

Question 5

Risk factors for paraphrenia

Answer 5

Female
Hearing/visual impairment 
Single, no children
CVAs
Social isolation

Question 6

Side-effects of acetylcholinesterase inhibitors

Answer 6

GI upset, incontinence, loss of appetite, dizziness, drowsiness, bradycardia
CI in asthma/COPD (except rivastigmine)

Question 7

Side-effects of memantine

Answer 7

Constipation, headache, dizziness, drowsiness, high blood pressure

Question 8

Alzheimer’s genetics

Answer 8

Parents - 3-4x higher risk

Familial dementia - more likely early onset

Question 9

Risk factors for Alzheimer’s disease

Answer 9

History of diabetes
Repeated head injury
History of depression
Vascular risk factors (HTN, stroke, cholesterol)
Increasing age
Family history of dementia
Low educational attainment

Question 10

Dementia (history)

Answer 10

• Clarify HPC (onset, duration)
• Explore memory difficulties (short-term, long-term)
• Orientation (day/dates, confused, recognizing people)
• Communication (word-finding, understanding, identify objects)
• Functioning (dressing, washing, toileting, walking, money, shopping, food, transportation)
• PMHx and risk factors (head injury, low mood)
• Risk (wandering, getting lost, fire, flooding, exploitation, abuse, aggression, self-injury).

Question 11

Dementia (medication)

Answer 11

• Clarify understanding
• Donepezil, rivastigmine, galantamine
• Purpose and mechanism (increase ACh, slow down progression, improve QoL)
• Duration and efficacy (40-50% respond, memory monitoring, 6m reviews)
• Side-effects/CIs (dizziness, drowsiness, low of appetite, bradycardia, GI upset, incontinence)
• Address other concerns and offer leaflets

Question 12

Vascular dementia (explanation)

Answer 12

• Clarify diagnosis and aetiology
• Progression and prognosis (mean survival 3 years)
• Explain medication (AChIs not indicated, control RFs, treat depression etc)
• Alternative treatment (lifestyle modification)
• Address other concerns and offer leaflets

Question 13

Lewy Body Dementia (explanation)

Answer 13

• Clarify diagnosis and aetiology (LBs affect chemicals)
• Common symptoms (falls, fluctuating cognition and hallucinations)
• Difference between LBD/PDD (1 year between Sx for PDD)
• Explain medication options (avoid antipsychotics, rivastigmine, PD meds - neurology)
• Alternative treatment (PT/OT)
• Address other concerns and offer leaflets

Question 14

Lewy Body Dementia (behaviour management)

Answer 14

• Clarify HPC (onset, duration)
• Clarify possible causes (medication change, illness)
• Explain medication options (increase current meds, add antipsychotic)
• Alternative treatment (re-orientation, MDT involvement, light therapy/sleep hygiene)
• Address other concerns

Question 15

Fronto-temporal dementia (history)

Answer 15

• Clarify HPC (onset, duration)
• Explore memory difficulties (short-term, long-term)
• Orientation (day/dates, confused, recognizing people)
• Communication (word-finding, understanding, identify objects)
• Explore frontal lobe Sx (personality, sexual inappropriateness, plans, mood, impulsivity, repetitiveness)
• Functioning (dressing, washing, toileting, walking, money, shopping, food, transportation)
• Risk (wandering, getting lost, fire, flooding, exploitation, abuse, aggression, self-injury).
• PMHx and risk factors (head injury, low mood)

Question 16

Mini-ACE cognitive examination

Answer 16

• Day/date/month/year (4)
• Animals in 1 min (7 for >22)
• Address x3 (7)
• Clock drawing (5)
• Address recall (7)
• Cut-off of 21 or 25

Question 17

Mild Cognitive Impairment (explanation)

Answer 17

• Clarify diagnosis and understanding
• Explain course and prognosis (5-10% per year conversion to dementia)
• Explain medication (no specific treatment, treat risk factors such as HTN/diabetes)
• Alternative treatment (lifestyle modification - diet, exercise, smoking)
• Address concerns and offer leaflet

Question 18

Delirium (history)

Answer 18

• Clarify HPC (onset, duration, orientation TPP)
• Clarify possible causes (PMHx, recent illness, medication change, constipation)
• Explore co-morbid symptoms (mood, enjoyment, sleep, appetite, psychosis)
• Risk (agitation, aggression, self-injury, wandering).
• Assess for underlying memory impairment (normal memory, dates, recognition, functioning, finances, wandering, risk).

Question 19

Delirium (management)

Answer 19

• Summarise case/formulation
• Explain DDx and possible aetiology
• Explain investigations (GP collateral, bloods, MSU)
• Management (location, treat cause, re-orientation, consistent nursing care etc.)
• Medications (haloperidol if QTc ok)
• Explain prognosis (usually 2-3 weeks)

Question 20

Indications for CT head in delirium

Answer 20

• new focal neurological signs
• a reduced level of consciousness (not adequately explained by another cause)
• a history of recent falls
• a head injury (patients of any age)
• anticoagulation therapy.
• non-resolving delirium where no clear cause is identified

Question 21

Mania in elderly patient (history)

Answer 21

• Clarify HPC (onset, duration)
• Elicit core mania symptoms (elation, irritability, energy, sleep, appetite, racing thoughts)
• Explore grandiose beliefs (special powers, challenge these)
• Explore auditory hallucinations (quality, content, number, 2nd/3rd person, commentary, commands, insight)
• Hallucinations in other modalities
• Thought interference and passivity phenomena
• Risk (Police, spending, disinhibition, suicidality)
• Alcohol and drugs
• Past psych Hx, PMHx, FHx, medications.

Question 22

Mania in elderly patient (explanation)

Answer 22

• Clarify diagnosis, rationale and DDx
• Clarify PPHx, PMHx, medication
• Explain treatment (inpatient/outpatient, MHA)
• Explain medication (mechanism, side-effects)
• Long-term management (CPN, CMHT)
• Address other concerns

Question 23

Frontal assessment battery

Answer 23

• Ask about visual/hearing difficulties
• Similarities (banana/orange, table/chair, tulip/rose/daisy)
• Verbal fluency (S-words, over 9 for 3 points)
• Programming (fist-edge-palm, x3 together then alone, 6 reps for 3 points)
• Conflicting instructions (tapping once/twice, 10 times)
• Inhibitory control (don’t tap when tap twice, 10 times)
• “Do not take my hands” (stroke palms)
• Cut off score of 12