Old Age Psychiatry Flashcards
What is dementia?
Aquired, chronic, progressive global cognitive impairment that interferes with activities of daily living.
What are causes of dementia?
Alzheimers (60%)
Vasculat (15%)
Lewy body Dementia (10%)
What are the two types of Alzheimers in terms of onset, and how do we classify them?
Late onset/sporadic (>65 yo): multiple gene involvement, including for protein APOE E4 (which cannot break down beta amyloid any more)
Familial / early onset: AD mutations
What are pathological features of AD?
Beta amyloid plaques
Neurofibrillary tangles (tau hyperphosphorylation)
Cortical atrophy
What fields does dementia present itself in?
Memory Language Problems Personality changes Subcortical symptoms
How does dementia affect memory?
Anterograde amnesia (forgetfulness, hard to lay down new memories)
Retrograde amnesia (loss of old memories, starting with more recent ones)
Disorientation in TIME, then PLACE, then PERSON
How does dementia affect language?
Receptive dysphagia: difficulty understanding
Expressive dysphagia: difficulty producing speech
What are behavioural symptoms of dementia?
restless, wandering disturbed sleep, night/day reversal Shouting, screaming, swearing Inappropriate, sexually disinhibited behaviour Aggression
What are psychological sx of dementia?
delusions
hallucinations
depression, anxiety
what are the 4 As of alzheimers?
Amnesia - recent memories lost first
Aphasia - inability to comprehend/formulate language
Apraxia - inability to perform everyday movements
Agnosia - inability to recognise objects
Describe aetiology of vascular dementia
Caused by small infarcts due to thromboemboli
what does CT for vascular dementia show
multiple small lucencies
what is the clinical presentation of vascular dementia
stepwise progression
symptoms dependent on site of infarcts
explain cause of lewy body dementia
deposition of lewy bodies in cyngulate nucelus and neocortex
what are lewy bodies made up of
alpha-synuclein and ubiquitin
what other disease also has lewy bodies, and where do they deposit
Parkinsons
they deposit in the brainstem
what is the clincal presentation of lewy body dementia
fluctuating confusion/alertnesss
Vivid visual hallycinations
Spontaneous parkinsonian signs
WHat must you NOT prescribe in lewy body dementia
do NOT prescribe haloperidol
what are differentials for dementia?
- exclude ORGANIC causes of REVERSIBLE dementia:
- Neuro: SOL, hydrocephalus, subdural haematoma
- Endo: hypothyroid, hyperparathyroid, Addisons, Cushings
- Vit deficiency: B12, folate, thiamine, niacin - Pseudodementia
- Delirium
what is pseudodementia
memory problems in severe depression
low mood BEFORE cognitive problems
how can you investigate dementia
Physical exam, basic obs
Blood tests: FBC (infection/anaemia), U&E (dehydration, renal failure, hyponatraemia), glucose, TFT (hypothyroid) , LFT (alcohol), B12, folate, calcium levels, VDLR (neurosyphilis)
MMSE / MOCA / AMTS
Collateral history +
Septic screen
CT/MRI head is suspecting neuro cause.
How do you manage dementia - SOCIAL
FOCUS ON SAFETY, QOL & PRESERVATION OF INDEPENDENCE
- Social:
- patient adaptations
- always carry ID, address, contact number
- Dossett boxes for medication
- change gas to electricity
- Reality orientation (visible clocks and calendars)
- Envirnoment modification (carpets)
- Assistive technology e.g. door mat buzzer
- Social support (personal care, meal prep, mediocation prompting). Consider day centre (enjoyable activities and social contact), day hospital (daily psychiatric care for more complex patients)
- Support carers
- Optimise physical health (treat auditory impairment, exclude superimposed delirium, treat underlying risk factors)
- PROVIDE SINGLE NAMED COORDINATOR
How do you manage dementia - PSYCH
Behavioural approach (identify and modify underlying triggers for difficulr and reisky behaviours)
Reminiscence therapy (validates sense of belonging)
Validation therapy (reassure and validate their emotion)
Multisensory therapy
Cognitive stimulation therapy
How do you manage dementia - BIO
Start doses LOW and increase SLOWLY
acetylcholinesterase inhibitors e.g. donepezil, rivastigmine
what is the MoA of acetylcholinesterase inhibitors
they increase acetylcholine supply by stopping acetylcholine breakdown
explain function of. Acherase inhibitors on. dementia
symptomatic relief
but does not stop progression
how do you manage severe alzheimers dementia
Memantine (NMDA Agonist)
what happens if you give antipsychotic to someone with Lewy body dementia?
it WORSENS IT - also they are dangerous
