Old age psychiatry Flashcards
what is the ABCD of dementia?
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
what are the cognitive features of dementia?
Memory (dysmnesia) – plus one of: Dysphagia (communication), Dyspraxia (inability to carry out motor skills), Dysgnosia (not recognising objects), Dysexecutive functioning, Functioning decline = ADLs
outline the different types of neuropsychiatric disturbance
- 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
what is a basic test of cognition for dementia? (correlates with ability to perform daily tasks)
MMSE, Montreal cognitive assessment tool
what are the types of dementia?
lewy body, vascular, alzheimers, mixed
How is Alzheimers disease diagnosed in primary care?
Case-finding, Clinical assessment, Differentiating AD from other causes of dementia, Management of AD
how is dementia clinically assessed?
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
DDX for dementia
delerium, depression
DEMENTIA VS DELERIUM
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
DEMENTIA VS DEPRESSION
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
Case 1 - Alzheimers dementia
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
Case 2 - miningioma presenting as dementia
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
Dementia with lewy bodies - pathology, presenting sy/sx, mx…
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
what scan is done?
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.
Case 3 -
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
Frontotemporal dementia - Pick’s disease - pahtology, sy/sx, ix…
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
Case 4 -
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.
What classes of drugs are used in the tx of dementia
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
what do Cholinesterase inhibitors do?
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
what other psychotropics are used?
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
what are Neuroleptics?
Used in patients with challenging behaviour, Controversy: Efficacy is small, Side effects = CVA and death, Drug may be given in food
what Non-pharmalogical tx are used?
Care homes
Capacity…
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
Power of Attorneys…
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
Guardianship…
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
Depression in the elderly
insomnnia, sypochondriasis, suicide agitation, aeitology - loss of health, wealth, spouse, work, home, Mx - antidepressants (tricyclic), CBT, ECT. Prognosis - 25%chronic.
Greif, mounring and bereavement - Normal…
Alarm, Numbness, Pining – manifest as illusions or hallucinations, Depression, Recovery and re-organisation
Greif, mounring and bereavement - Abnnormal…
Persisted beyond 2 months, Guilt, Thoughts of death, Worthlessness, Psychomotor retardation, Prolonged and marked functional impairment, Psychosis
what factors influence suicide in the elderly?
lonliness, widowed, ill health, chronic pain, recent life events. M>F.
Late onset schizophrenia like psychosis…
aetiology - sensory loss, social isolationn, genetic? Sy/sx - Spectrum from circumscribed persecutory delusions to full schizophrenia-like psychosis, Mx - nneuroleptics, admission, increase social contact
Car/ fitness to drive…
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
