Old age psychiatry

Question 1

what is the ABCD of dementia?

Answer 1

A = activities of daily living (ADLs), B = behavioural and psychiatric symptoms of dementia (BPSD), C = cognitive impairment – in more than one area, D = decline – over 6 months, get a collateral hx from family members

Question 2

what are the cognitive features of dementia?

Answer 2

Memory (dysmnesia) – plus one of: Dysphagia (communication), Dyspraxia (inability to carry out motor skills), Dysgnosia (not recognising objects), Dysexecutive functioning, Functioning decline = ADLs

Question 3

outline the different types of neuropsychiatric disturbance

Answer 3

• Psychosis = can be delusions – often of a paranoid nature
• Depression – might not present typically e.g. not eating/sleeping
• Altered circadian rhythms – changes in sleep/wake cycle can create problems with carer stress
• Agitation – goes hand in hand with other symptoms
• Anxiety – links with depression

Question 4

what is a basic test of cognition for dementia? (correlates with ability to perform daily tasks)

Answer 4

MMSE, Montreal cognitive assessment tool

Question 5

what are the types of dementia?

Answer 5

lewy body, vascular, alzheimers, mixed

Question 6

How is Alzheimers disease diagnosed in primary care?

Answer 6

Case-finding, Clinical assessment, Differentiating AD from other causes of dementia, Management of AD

Question 7

how is dementia clinically assessed?

Answer 7

History and collateral, Risk assessment, Cognitive testing – MMSE/MOCA, Physical and bloods, Neuroimaging, SPECT comparison, Follow up for 1 year, Consider care needs/support for others

Question 8

DDX for dementia

Answer 8

delerium, depression

Question 9

DEMENTIA VS DELERIUM

Answer 9

DEMENTIA: Insidious onset with unknown date
Slow, gradual, progressive decline
Generally irreversible
Slight day-to-day variation
Psychomotor changes late in illness
DELERIUM: Abrupt, precise onset, known date
Acute illness, lasting days or weeks
Usually reversible (treatable cause)
Variable, hour by hour
Marked early psychomotor changes

Question 10

DEMENTIA VS DEPRESSION

Answer 10

DEMENTIA: Insidious onset
No psychiatric history
Mood fluctuation day-to-day
Memory loss occurs first
Associated with a decline in social function
DEPRESSION: Abrupt onset
History of depression
Diurnal variation in mood
Depressed mood coincides with memory loss
Associated with anxiety

Question 11

Case 1 - Alzheimers dementia

Answer 11

78f, 3 year history of gradual and progressive deterioration in ‘memory’, On cognitive testing she has some dysmnesia and dysexecutive dysfunction, Clear, functional impairment – reliant on daughter, No focal neurological signs, No history of vascular disease or risk factors, Diagnosis? Would you order imaging?
Order MRI, can see atrophy in the medial and tempral lobes/ can also do a SPECT comparison

Question 12

Case 2 - miningioma presenting as dementia

Answer 12

74f, subtle personality changes, lack of motivation and progressive apathy, On cognitive testing she has some executive dysfunction but intact memory, Reports constant dull headache, No focal neurological signs, Diagnosis? Imaging?
Obvious heavily calcified lesion in left frontal region suggestive of meningioma, Referred to neurosurgeons who resected meningioma, After period of recovery cognition and personality revovered

Question 13

Dementia with lewy bodies - pathology, presenting sy/sx, mx…

Answer 13

Pathology: Lewy Bodies in occipito-parital cortex
PC: Fluctuating cognitive dysfunction, visual, hallucinations, parkinsonism, Deficits of attention, frontal executive, visuospatial, sleep disorders, abonrmal DAT scan.
Rx: cholinesterase inhibitors

Question 14

what scan is done?

Answer 14

DAT scan - The DATScan on a normal or AD patient will show normal re-uptake of the dopamine transporter in the head of the caudate nucleus and putamen in the shape of a ‘comma’, whereas in DLB, re-uptake in the putamen is reduced, leading to the ‘full-stop’ sign.

Question 15

Case 3 -

Answer 15

50 year old man presents to clinic. Worked as an IT technician for last 10 years, Gradual change in his behaviour over last 2 years. Stopped taking care of his appearance and personal hygiene.Clear personality change. Apathetic and withdrawn, Used to be tidy but house now chaotic, Diagnosis? Imaging?
Axial MRI images shows cerebral atrophy that is more pronounced in the frontal and temporal regions
Note the difference in the gyro thickness and size of the sulci between the frontotemporal region and the parietal/occipital region

Question 16

Frontotemporal dementia - Pick’s disease - pahtology, sy/sx, ix…

Answer 16

Path: Pick Bodies
PC: disinhibition, personality change, early memory, preservation, progressive aphasia
Ix: MRI – frontal or temporal atrophy
Behavioural disorder = personality change, Speech disorder – altered output, stereotypy, echolalia, perseveration, mutism, Neuropsychology – frontal dysexecutive syndrome, Memory, praxis and visuospatial function not severely impaired, Neuroimaging – abnormalities in frontotemporal lobes, Neurological signs commonly absent early – parkinsonism later, MND in a few, autonomic, incontinence, primitive reflexes

Question 17

Case 4 -

Answer 17

69 year old man brought in by daughter concerned about his memory, Symptoms started a year prior, when he began losing things around the house and getting lost when out walking, Daughter feels he was more irritable and his speech was less fluent, On warfarin for atrial fibrillation and no history of head injury or focal neurology on examination.
Gyri on left frontotemporal region (right of image) separated from skull by hypodense material. This is clotted blood. Patient has chronic subdural haematoma.
Neurosurgical consultation advised. In acute subdural haematoma, fresh blood may appear hyperdense. In sub-acute may appear isodense, making radiological diagnosis difficult.

Question 18

What classes of drugs are used in the tx of dementia

Answer 18

Acetylcholinesterase Inhibitors (AChEI) for mild to moderate dementia = Donepezil, rivastigmine, galantamine
Lewy body dementia = rivastigmine
Memantine for moderate to severe dementia
Also used if AChEI is not tolerated

Question 19

what do Cholinesterase inhibitors do?

Answer 19

Slow down the decline – do not stop disease progression, Improve the non-cognitive symptoms, Safe but there are some side effects, Nausea, vomiting, diarrhoea, Fatigue, insomnia, Muscle cramps, Headaches, dizziness, If medication is stopped then a big decline in cognitive function will be experienced

Question 20

what other psychotropics are used?

Answer 20

Non-pharmacological measures first, Most are used off-license
Antipsychotics – e.g. risperidone, amisulpride
Antidepressants – e.g. mirtazapine, sertraline
Anxiolytics – e.g. lorazepam
Hypnotics – e.g. zolpidem, zopiclone, clonazepam
Anticonvulsants – e.g. valproate, carbamazepine

Question 21

what are Neuroleptics?

Answer 21

Used in patients with challenging behaviour, Controversy: Efficacy is small, Side effects = CVA and death, Drug may be given in food

Question 22

what Non-pharmalogical tx are used?

Answer 22

Care homes

Question 23

Capacity…

Answer 23

Patient will have capacity if they can: Act independently, Make decisions, Communicate, Understand situations , Retain information long enough to make decision - Capacity is task specific

Question 24

Power of Attorneys…

Answer 24

Finance: Usually easier to retain capacity for finance than for welfare cases/ Welfare = bigger issues than finance/ Solicitor is needed to assess capacity/ Power of attorney is required to act in best interest

Question 25

Guardianship…

Answer 25

If someone doesn’t already have a power of attorney in place but suddenly loses capacity – need guardianship order. Finance, Welfare, Needs two medical certificates from: GP, Psychiatry Detailed report from mental health officer = social worker, Will take into account family and those nominated, Assess is it needed and is it agreed? Decide who the guardian will be

Question 26

Depression in the elderly

Answer 26

insomnnia, sypochondriasis, suicide agitation, aeitology - loss of health, wealth, spouse, work, home, Mx - antidepressants (tricyclic), CBT, ECT. Prognosis - 25%chronic.

Question 27

Greif, mounring and bereavement - Normal…

Answer 27

Alarm, Numbness, Pining – manifest as illusions or hallucinations, Depression, Recovery and re-organisation

Question 28

Greif, mounring and bereavement - Abnnormal…

Answer 28

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

Question 29

what factors influence suicide in the elderly?

Answer 29

lonliness, widowed, ill health, chronic pain, recent life events. M>F.

Question 30

Late onset schizophrenia like psychosis…

Answer 30

aetiology - sensory loss, social isolationn, genetic? Sy/sx - Spectrum from circumscribed persecutory delusions to full schizophrenia-like psychosis, Mx - nneuroleptics, admission, increase social contact

Question 31

Car/ fitness to drive…

Answer 31

Applies to dementia or organic brain syndrome: Notify DVLA upon diagnosis, If early dementia – then license may be decided yearly, “those with poor short term memory, disorientation or lack of insight should almost certainly not drive” – DVLA