Old Age Psychiatry Flashcards
Life expectancy (UK)
⁃ 41 years in 1840
⁃ 46 years in 1900
⁃ 69 years in 1950
⁃ 80 years in 2011
CAPE
Used to assess QOL, cognitive deficits and physical dependency levels in the elderly
15-25mins
Use to differentiate between organic brain disease and functional psychiatric disorders
Scores can be used to predict likelihood of hospital discharge
Used to assist in the identification of most appropriate placement
Clock drawing test
Screening test for cognitive dysfunction - visuospatial ability, motor function, attention, comprehension
Asked to draw clock: 10mins past 11.
Parkinson’s disease sx
Rigidity
Bradykinesia (slowing of movement)
Tremor - pill rolling, 5Hz
Intention tremor - frequency
2-3Hz
Essential tremor - frequency
7Hz
Physiological tremor - frequency
10Hz
Parkinson’s disease - pathology
Degeneration of dopaminergic neurons in the pars compacta of the SN
Accumulation of alpha synuclein - abnormal protein accumulations are referred to as Lewy bodies
PD dementia
Marked problems with executive function. Verbal and visual memory are affected to a lesser extent.
Cholinesterase inhibitors used to improve cognitive performance
Psychosis in Parkinson’s
Hallucinations esp visual are common
Thought to be due to dopaminergic medication - anticholinergics and dopamine agonists are higher risk
Low dose quetiapine best tolerated
Cholinesterase inhibitors also used
Treatment of Parkinson’s disease
Dopamine receptor agonists e.g. apomorphine, ropinirole
Associated with impulse control disorders inc pathological gambling, binge eating and hypersexuality
Post-stroke depression
30-40%
Lesions in left hemisphere basal ganglia esp
SSRIs, mirtazapine and nortriptyline
If pt is on warfarin then citalopram or escitalopram is recommended
Reversible causes of DEMENTIA
Drugs and alcohol Emotions (depression) Metabolic (hypo and hyper thyroid) Eyes and ears in decline Normal pressure hydrocephalus Tumour (or SOL) Infection (syphilis and AIDS) Anaemia (vit B12 or folate def)
Other metabolic causes of dementia
Wilson's disease Hashimotos encephalitis Hyper and hypo parathyroidism Cushing's disease Addisons disease
Other infectious causes of dementia
Whipples disease
Sarcoidosis
Meningitis
Dementia due to HIV
HIV associated dementia (AID-dementia complex), HIV encephalopathy, and subacute encephalitis occur late in the illness in about 1/3 of pts
Insidious onset
Effects of chronic alcohol misuse on the brain
Enlarged lateral ventricles
Loss of grey matter in both cortical and subcortical areas
Remit to some extent with cessation of alcohol use
Huntington’s disease - Pathology
- Trinucleotide repeat of CAG - between 37-120 repeats on chromosome 4
- Reduced BAGA neurons in the basal ganglia, leading to increased stimulation of the thalamic and cortex of GP
- Increase in dopamine transmission
Huntington’s disease - Presentation
Chorea, dementia and family history
Onset: 30s-40s, under 20 is juvenile HD
Death within 10-12 years
Chorea
movement disorder characterised by initial jerks, tics, gross involuntary movements of all parts of the body, grimacing, dysarthria
HD - Psychiatric symptoms
60-75% Anxiety and depression Psychosis Aggression and violence Subcortical dementia - slowing, apathy, amnesia
Vitamin B12 deficiency - causes
Decreased intake Poor absorption Intrinsic factor deficiency (pernicious anaemia) Chronic pancreatic disease Parasites Intestinal disease Metabolic impairment
Vitamin B12 deficiency - sx
- weakness, fatigue, anorexia, failure to thrive, irritability
- developmental delay, paraesthesias, seizures, ataxia, dementia, abnormal movements, depression
- macrocytosis, anaemia, leukopenia, pancytopenia
- glossitis, skin hyperpigmentation, d&v, icterus
Dementia - prevalence
in over 65s - 7.1% (1.3% entire UK population)
Prevalence doubles for every 5yr increase in age after 65
2% of affected are under 65
Dementia - proportions
- Alzheimer’s disease (62%)
- Vascular (17%)
- Lewy body dementia (4%).
UK specific epidemiological findings
• The prevalence of early onset dementia has been found to be higher in men than in women for those aged 50-65, while late onset dementia is considered to be marginally more prevalent in women than in men.
• Approximately 60% of people with dementia are thought to live in private
households.
Cortical dementia - presentation
⁃ Impaired memory
⁃ Impaired visuospatial ability
⁃ Impaired executive function
⁃ Impaired language
Cortical dementia - examples
⁃ Alzheimer’s disease
⁃ Pick’s disease
⁃ Creutzfeldt-Jakob disease
Subcortical dementia - presentation
⁃ Generalised slowing of mental processes
⁃ Personality change
⁃ Mood disorders
⁃ Presence of abnormal movements
Subcortical dementia - examples
⁃ Binswanger’s disease
⁃ Dementia associated Huntington’s disease
⁃ Dementia associated AIDS
⁃ Dementia associated with Parkinson’s disease
⁃ Dementia associated with Wilson’s disease
⁃ Dementia associated with progressive supranuclear palsy
To differentiate between AD, vascular and FTD use…
HMPAO SPECT (but not in Down's syndrome) If this is unavailable - FDGPET
Imaging for LBD
FP-CIT SPECT
Test for CJD
Cerebrospinal fluid examination
Test of delirium, FTD or CJD suspected or if seizures
EEG
Antipsychotics for BPSD
CATIE-AD trial - risperidone and olanzapine
Risperidone is the only licensed drug (6w)
- A/w increased mortality
Alzheimer’s disease - dementia - Epidemiology
60% of dementia
Overall prevalence in those aged 60 or older is 5-7%
Risk of developing is 1% at age 60, doubling every 5 years (30-50% by age 85)
Early onset AD - genes
• Autosomal dominant mode of inheritance
• Causative mutations have been identified in 3 genes:
⁃ Amyloid precursor protein (APP) - chromosome 21
⁃ Presenilin 1 (PSEN1) - chromosome 14
⁃ Presenilin 2 (PSEN2) - chromosome 1
Late onset AD - genes
• The genetic predisposition has been confirmed as associated with polymorphisms in the apolipoprotein E (apoE) gene
⁃ In Caucasians, apoE2 reduces the risk of Alzheimer’s
⁃ ApoE3 - the commonest form - is neutral
⁃ ApoE4 accounts for about 50% of the vulnerability to late-onset Alzheimer’s
⁃ Promotes earlier disease onset by a decade
⁃ ApoE4 heterozygotes have a threefold increased risk
⁃ ApoE4 homozygotes have an eightfold increased risk
⁃ (Note: ApoE4 is not a determinant of disease - at least one-third of
patients are apoE4-negative, and many homozygotes do not develop Alzheimer’s
⁃ It is thought to increase risk by interaction with beta-amyloid metabolism and clearance from the brain)
Medications reducing rate of dementia and Alzheimer’s disease
NSAIDS
HRT
Statins
Amyloid cascade hypothesis
• It proposes that the central pathogenic event is increased formation and deposition of beta-amyloid, particularly the 42-amino acid variant.
- The other pathological changes - e.g. neurofibrillary tangles and involvement
of tau - were thought to be downstream of this causal process.
Inflammatory mechanism for AD
Microglial activation
The cholinergic hypothesis
Based on 1970s findings that there is severe and widespread loss of acetylcholine in the cerebral cortex - due to atrophy of cells in the nucleus basalts of Meynert
Risk factors for developing AD
Age FH Head trauma - with LOC HTN Heart disease DM CVA High cholesterol Lower educational level Female gender NOT aluminium
Core features of AD
- Amnesia - memory impairment with gradual onset and continuing decline
- Aphasia
- Apraxia
- Agnosia
- Anosmia
- Disturbance in executive function (e.g. planning, reasoning)
Other features of AD
- Depression
- Psychosis
- Behavioural symptoms (e.g. agitation, wandering)
- Personality change
AD and SPECT
temporal and parietal hypoperfusion
