Old Age Psychiatry

Question 1

Describe risk factors which are associated with the development of psychiatric illness in the elderly

Answer 1

• decline in functional ability
• more likely to experience bereavement
• decline in SES with retirement
• vulnerable to elder abuse
• at risk of loss of dignity and respect
• all these stresses can result in isolation, loneliness or psychological stress which can contribute to mental health problems

Question 2

What are the main clinical features of neurotic disorders in the elderly?

Answer 2

• non specific anxiety and depressive symptoms predominate

- hypochondriasis common

Question 3

Describe the 3 broad categories of psychosis in the elderly

Answer 3

1. old psychosis - developed earlier in adult life
2. new psychosis - develops later in life; referred directly to old age services
   
   • rare
3. other conditions which give rise to paranoid and/or hallucinatory symptoms but which are not primarily psychotic illness (includes delirium, dementia, affective disorder and hallucinations of sensory deprivation)

Question 4

How do positive psychotic symptoms differ in the elderly?

Answer 4

• more likely to experience hallucinations
• persecutory delusions are common
• partition delusions are a notable feature in this group

Question 5

Describe common features of depression in the elderly

Answer 5

• severe psychomotor retardation/agitation commomn
• degree of cognitive impairment (depressive pseudodementia)
• depressive delusions and paranoia
• somatic symptoms may predominate

Question 6

How does aging impact pharmacokinetics?

1. absorption
2. distribution
3. metabolism
4. excretion
5. What are the impacts of this on prescribing?

Answer 6

1. reductions in gastric pH, mesenteric blood flow and gut motility reduce rate of drug absorption
2. reduced body mass with proportionally increased body fat, reduced body water and reduced albumin cause increased levels of free drug and longer half lives
3. decreased hepatic blood flow and reduced efficiency of hepatic enzymes
4. reduction in renal clearance
5. drug effects are generally prolonged and cumulative, and the risk of toxicity is high
   - start with a very low dose and titrate up slowly

Question 7

What is delirium?

Answer 7

acute, fluctuating change in mental status, with inattention, disorganised thinking and altered levels of consciousness
MEDICAL EMERGENCY (associated with high morbidity and mortality)

Question 8

Describe some indicators of delirium

Answer 8

• disturbance in cognitive function - worsened concentration, slow responses, confusion, memory deficit
• disturbance in perception - auditory or visual hallucinations
• alterations in physical function - reduced mobility, reduced movement; restlessness, agitation, changes in appetite; sleep disturbance
• alteration in social behaviour - poor co-operation, withdrawal or alterations in communication

Question 9

Name some causes of delirium

Answer 9

• systemic infection/infection associated with pyrexia
• metabolic disturbance
• vitamin deficiency (thiamine; B12)
• hypothyroidism
• cushing’s
• Intracranial pathology
• drug intoxication
• drug/alcohol withdrawal
• postoperative states

Question 10

Name some predisposing factors for delirium

Answer 10

• extremes of age
• neurological pathology
• unfamiliar environment
• sleep deprivation
• sensory extremes (overload or deprivation)
• immobilisation
• visual or hearing impairment

Question 11

How is delirium managed?

Answer 11

• investigate and treat underlying disease
• care for patient in quiet single room
• review (and if possible stop) all drug therapy
• ensure patients have hearing aids, glasses and dentures
• lorazepam can help manage agitation
• avoid psychoactive drug

Question 12

How can delirium be prevented?

Answer 12

• orientation/therapeutic activity
• early mobilisation
• avoidance of polypharmacy
• prevention of dehydration
• prevention of sleep deprivation
• effective communication

Question 13

What is dementia?

Answer 13

• a syndrome of symptoms caused by organic disease of the brain
• disturbance of multiple higher level cortical functioning processes, but with clear consciousness

Question 14

What things are important to ask about in a hx for dementia

Answer 14

• context - personal and collateral account of developments over the past 12 months
• onset
• description of cognitive problems
• any behavioural changes
• any positive symptoms - hallucinations
• any movement disturbance
• effects on daily life
• any symptoms of physical illness
• medications
• mini cognitive function assessment

Question 15

How does dementia differ from normal ageing and mild cognitive impairment

Answer 15

there is impact on daily functioning

Question 16

How can dementia be distinguished from delirium in terms of:

1. onset
2. course of impairment
3. symptoms
4. motor activity
5. emotional changes

Answer 16

1. delirium is rapid onset; dementia is more insidious
2. delirum follows fluctuating course; dementia is less fluctuating
3. psychotic symptoms are more prominent in dementia
4. motor activity is abnormal in delirium; less likely to be affected
5. emotional changes are more prominent and variable in delirium

Question 17

How does Dementia differ from Depressive Pseudodementia in terms of:

1. onset and hx
2. previous psych hx
3. insight
4. time of day symptoms are worse
5. MSE

Answer 17

1. dementia has longer hx, insidious onset and no precipitant
   depresison is shorter hx, often with a precipitant
2. previous hx of depression common in depressive psuedodementia
3. patient with depressive pseudodementia has insight into memory problems, whilst insight is less likely with dementia
4. symptoms of depressive pseudodementia often worse in morning
   symptoms of dementia often worse in evening
5. Depression
   - variable performance
   - may convey distress
   - not attempt questions or “i don’t know” answers
   - depressive cognitions present

Dementia

• labile mood
• more consistent performance
• attempt to answer questions; may confabulate answers

Question 18

1. What is amnesic syndrome?
2. Name some features of amnesic syndrome
3. Name some causes of amnesic syndrome

Answer 18

1. impairment in recent memory - difficulties in learning new material; preservation of immediate recall
2. confabulation
   impairment in time sense
   anterograde amnesia and some retrograde amnesia
   may be accompanied by personality change

3. alcohol abuse
    long term heavy drug use
    toxins
    head trauma
    stroke and cerebrovascular disease
    post infection

Question 19

Name 3 reversible causes of memory problems that are differentials for dementia

Answer 19

1. alcohol abuse
2. vitamin deficiency
3. thyroid problems

Question 20

Name 2 tools which are useful in the screening/assessment of dementia

Answer 20

1. Addenbrooke’s Cognitive Examination (ACE-3)

2. 6 item cognitive impairment test

Question 21

Which cognitive functions are affected in Alzheimer’s Disease (6)

Answer 21

1. memory
2. language
3. motor skills
4. recognition skills - changes in ability to process and interpret visual info leading to problems in spacial awareness and facial recognition
5. ADL (due to difficulties with decision making, problem solving, planning and sequencing tasks)
6. personality

Question 22

Name 2 pharmacological agents used in the management of alzheimer’s disease

Answer 22

1. AcH esterase inhibitors - donepezil; rivastigmine
   - can only be used until all AcH has been depleted
2. Memantine - NMDA antagonist; reduces the effects of glutamate toxicity

Question 23

1. What is the disease course of vascular dementia
   a) large and medium vessel disease
   b) small vessel disease
2. In vascular dementia, what are the deficits dependent on?
3. Which other type of dementia does vascular dementia commonly co-occur with?

Answer 23

1a) sudden onset and stepwise deterioration
1b) insidious onset; gradual progression

2. damaged region
3. alzheimers

Question 24

1. How can lewy body dementia and PD with dementia be distinguished?
2. Name the diagnostic crtieria for Lewy Body dementia

Answer 24

1. motor symptoms predominate in PD with dementia
   mild parkinsonian features with rapid dementia in lewy body dementia
2. progressive dementia plus 2 of the following:
   - fluctuations in cognition/performance
   - persistent well formed hallucinations
   - parkinsonism

Question 25

What are the features of behavioural variant frontotemporal dementia?

Answer 25

- disinhibition, personality change - apathy, withdrawal self neglect - stereotypical, compulsive behaviour - emotional blunting - abnormal eating - craving sweets

Question 26

What are the features of primary progressive aphasia?

Answer 26

- reduced speech fluency - articulation problems - phonological and syntactical errors - preservation of comprehension

Question 27

What are the features of semantic dementia?

Answer 27

- preservation of fluency, phonology and syntax | - difficulty naming and comprehension