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MRCPsych Paper B > Old Age Psychiatry > Flashcards

Old Age Psychiatry Flashcards

1
Q

Life expectancy (UK)

A

⁃ 41 years in 1840
⁃ 46 years in 1900
⁃ 69 years in 1950
⁃ 80 years in 2011

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2
Q

CAPE

A

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

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3
Q

Clock drawing test

A

Screening test for cognitive dysfunction - visuospatial ability, motor function, attention, comprehension
Asked to draw clock: 10mins past 11.

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4
Q

Parkinson’s disease sx

A

Rigidity
Bradykinesia (slowing of movement)
Tremor - pill rolling, 5Hz

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5
Q

Intention tremor - frequency

A

2-3Hz

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6
Q

Essential tremor - frequency

A

7Hz

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7
Q

Physiological tremor - frequency

A

10Hz

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8
Q

Parkinson’s disease - pathology

A

Degeneration of dopaminergic neurons in the pars compacta of the SN
Accumulation of alpha synuclein - abnormal protein accumulations are referred to as Lewy bodies

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9
Q

PD dementia

A

Marked problems with executive function. Verbal and visual memory are affected to a lesser extent.
Cholinesterase inhibitors used to improve cognitive performance

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10
Q

Psychosis in Parkinson’s

A

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

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11
Q

Treatment of Parkinson’s disease

A

Dopamine receptor agonists e.g. apomorphine, ropinirole

Associated with impulse control disorders inc pathological gambling, binge eating and hypersexuality

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12
Q

Post-stroke depression

A

30-40%
Lesions in left hemisphere basal ganglia esp
SSRIs, mirtazapine and nortriptyline
If pt is on warfarin then citalopram or escitalopram is recommended

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13
Q

Reversible causes of DEMENTIA

A 
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)
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14
Q

Other metabolic causes of dementia

A 
Wilson's disease
Hashimotos encephalitis
Hyper and hypo parathyroidism
Cushing's disease
Addisons disease
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15
Q

Other infectious causes of dementia

A

Whipples disease
Sarcoidosis
Meningitis

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16
Q

Dementia due to HIV

A

HIV associated dementia (AID-dementia complex), HIV encephalopathy, and subacute encephalitis occur late in the illness in about 1/3 of pts
Insidious onset

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17
Q

Effects of chronic alcohol misuse on the brain

A

Enlarged lateral ventricles
Loss of grey matter in both cortical and subcortical areas
Remit to some extent with cessation of alcohol use

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18
Q

Huntington’s disease - Pathology

A
  • 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
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19
Q

Huntington’s disease - Presentation

A

Chorea, dementia and family history
Onset: 30s-40s, under 20 is juvenile HD
Death within 10-12 years

20
Q

Chorea

A

movement disorder characterised by initial jerks, tics, gross involuntary movements of all parts of the body, grimacing, dysarthria

21
Q

HD - Psychiatric symptoms

A 
60-75%
Anxiety and depression
Psychosis
Aggression and violence
Subcortical dementia - slowing, apathy, amnesia
22
Q

Vitamin B12 deficiency - causes

A 
Decreased intake
Poor absorption
Intrinsic factor deficiency (pernicious anaemia)
Chronic pancreatic disease
Parasites
Intestinal disease
Metabolic impairment
23
Q

Vitamin B12 deficiency - sx

A
  • 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
24
Q

Dementia - prevalence

A

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

25
Q

Dementia - proportions

A
  • Alzheimer’s disease (62%)
  • Vascular (17%)
  • Lewy body dementia (4%).
26
Q

UK specific epidemiological findings

A

• 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.

27
Q

Cortical dementia - presentation

A

⁃ Impaired memory
⁃ Impaired visuospatial ability
⁃ Impaired executive function
⁃ Impaired language

28
Q

Cortical dementia - examples

A

⁃ Alzheimer’s disease
⁃ Pick’s disease
⁃ Creutzfeldt-Jakob disease

29
Q

Subcortical dementia - presentation

A

⁃ Generalised slowing of mental processes
⁃ Personality change
⁃ Mood disorders
⁃ Presence of abnormal movements

30
Q

Subcortical dementia - examples

A

⁃ 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

31
Q

To differentiate between AD, vascular and FTD use…

A 
HMPAO SPECT (but not in Down's syndrome)
If this is unavailable - FDGPET
32
Q

Imaging for LBD

A

FP-CIT SPECT

33
Q

Test for CJD

A

Cerebrospinal fluid examination

34
Q

Test of delirium, FTD or CJD suspected or if seizures

A

EEG

35
Q

Antipsychotics for BPSD

A

CATIE-AD trial - risperidone and olanzapine
Risperidone is the only licensed drug (6w)
- A/w increased mortality

36
Q

Alzheimer’s disease - dementia - Epidemiology

A

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)

37
Q

Early onset AD - genes

A

• 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

38
Q

Late onset AD - genes

A

• 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)

39
Q

Medications reducing rate of dementia and Alzheimer’s disease

A

NSAIDS
HRT
Statins

40
Q

Amyloid cascade hypothesis

A

• 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.

41
Q

Inflammatory mechanism for AD

A

Microglial activation

42
Q

The cholinergic hypothesis

A

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

43
Q

Risk factors for developing AD

A 
Age
FH
Head trauma - with LOC
HTN
Heart disease
DM
CVA
High cholesterol
Lower educational level
Female gender
NOT aluminium
44
Q

Core features of AD

A
  • Amnesia - memory impairment with gradual onset and continuing decline
  • Aphasia
  • Apraxia
  • Agnosia
  • Anosmia
  • Disturbance in executive function (e.g. planning, reasoning)
45
Q

Other features of AD

A
  • Depression
  • Psychosis
  • Behavioural symptoms (e.g. agitation, wandering)
  • Personality change
46
Q

AD and SPECT

A

temporal and parietal hypoperfusion

MRCPsych Paper B (3 decks)

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