Old Age Psychiatry Flashcards
Define Delirium
Acute transient global organic disorder of CNS resulting in impaired consciousness and attention
There are three types of delirium. Describe Hypoactive Delirium
Lethargy
Reduced motor activity
Apathy
Sleepiness
There are three types of delirium. Describe Hyperactive Delirium
Agitated
Aggressive
Hallucinations and Delusions
What is the third type of Delirium?
Mixed
There are many different causes of Delirium. Using the mnemonic THINk DELIRIUM, describe them
Trauma, Hypoxia, Increased age, NOF fracture, smoKer, Drugs, Environment, Lack of sleep, Imbalanced electrolytes, Retention, Infection, Uncontrolled Pain, Medical Conditions
Delirium is Acute in onset and fluctuating in course. Using the mnemonic DELIRIUM describe the classical presenting features
Disordered thinking, Euphoric, Language Impaired, Illusions (+/ - delusions or hallucinations), Reversal of sleep wake pattern, Inattention, Unaware (Disorientated), Memory Deficits
State the five ICD10 requirements for Delirium diagnosis
- Impairment of consciousness and attention
- Global disturbance in cognition
- Psychomotor disturbance
- Disturbance of sleep wake cycle
- Emotional disturbance
Name five immediate investigations you would do for a Delirious patient
Nutritional and Hydration Status Systems Examination Urinalysis Bloods (confusion screen) CXR
Describe the (10) features of an AMT (Abbreviated Mental Test)
Age, Time, (Recall 42 West Street at end), Year, Current Location, Identify two people, DOB, Date of WW1, Current Monarch, Count backwards from 20
Describe the features of CAM (Confusion Assessment Method)
Diagnosis involves the presence of 1 and 2 and 3/4
1) Acute Onset and Fluctuating Course
2) Inattention (demonstrated by serial 7s test)
3) Disorganised thinking (incoherent speech)
4) Altered consciousness
The mainstay of Delirium treatment is treating the underlying cause and providing reassurance. How can the patients environment be optimised?
Quiet
Well lit
Consistent staff
Encouraging visitation
How should the behaviour of Delirious patients be managed?
Medication should be a last resort
Oral low dose Haloperidol or Olanzepine
Avoid Benzodiazepines
Define Dementia
Generalised decline of memory, intellect and personality without impairment in consciousness leading to functional impairment
Name 4 irreversible causes of Dementia
Neurodegenerative
Infections (HIV, CJD)
Vascular
Traumatic Head Injury
Name 4 reversible causes of Dementia
Visual/Hearing impairment,
Nutritional Deficiencies
Normal pressure hydrocephalus
Hypothyroidism
What is Vascular Dementia?
Occurs as a result of Cerebrovascular Disease (stroke, multiple infarcts, or chronic changes such as Atherosclerosis)
What is Lewy Body Dementia?
Abnormal deposition of Lewy Body proteins throughout the cortex and brainstem
If outside brainstem - more profound cholinergic loss
If within brainstem - more profound dopaminergic loss and Parkinsonian sx
What is Frontotemporal Dementia?
Atrophy of Frontotemporal Lobes
One type is Picks disease (characterised histologically by Picks Proteins)
Dementia can be Cortical (such as Alzheimer’s and Frontotemporal). Give four clinical features.
Severe Memory Loss
Early Aphasia
Apraxia
Normal Coordination
Dementia can be Sub-Cortical (such as DLB). Give four clinical features.
Moderate Memory Loss
Impaired Coordination
Slow Motor Speed
May have Dysarthria
Give an example of mixed Cortical and Subcortical Dementia
Vascular
Describe the genetic risks for developing Alzheimer’s
Early Onset - Presenilin 1 and 2, Amyloid Precursor Protein
Late Onset - ApoE 4
Describe the ICD10 criteria A-D for Dementia
A - evidence of decline in memory and other cognitive abilities
B - Preserved awareness for long enough to demonstrate A
C - Decline in emotional control/motivation/behaviour
D - A must be present for 6 months
What are the parameters for Presenile and Senile Dementia?
Presenile is <65
Senile is >65
Describe the features of early Alzheimer’s
Memory lapses
Difficulty finding words
Forgetting names of people/places
Describe the late stages of Alzheimer’s
Disorientation I time and place
Apathy
Incontinence
Agitation
Describe the ICD10 criteria for early onset Alzheimer’s
A - General criteria for Alzheimer’s met and age <65
B - Atleast one of: relatively rapid onset and progression, aphasia/agraphia/apraxia/alexia
Describe the ICD10 criteria for late onset Alzheimer’s
A - General Alzheimer’s criteria met and age >65
B - Atleast one of: Slow gradual onset and progression, predominance of memory impairment over intellectual ability
How does Vascular Dementia typically present?
Late sixties/early seventies Stepwise deterioration Confusion Early personality changes and Emotional May have signs of cardiovascular disease
What is Mixed Dementia?
Features of both Alzheimer’s and Vascular
Name four features of DLB
Day to day fluctuations
Recurrent visual hallucinations
Motor signs of Parkinsonism
Severe sensitivity to Neuroleptic drugs
Describe four clinical features of Frontotemporal Dementia
Usually 50-60 y/o
Worsening of social behaviour
Personality changes such as disinhibition/apathy/restlessness
Memory is preserved in early stages
How does Huntington’s Disease present?
Abnormal Choreiform Movements
Dementia Symptoms presenting later on
Autosomal dominant so strong FH
What is the triad of Normal Pressure Hydrocephalus
Dementia with frontal lobe disturbance
Urinary Incontinence
Gait disturbance (wide)
Describe three features of Creutzfield Jakob Disease
Onset usually <65
Rapid progression and death within 2y
Disintegration of all higher cerebral functions
How is suspected dementia investigated?
Initially referred to memory clinic
Routine panels of bloods
What imaging is used to differentiate Alzheimer’s, Vascular and Frontotemporal?
SPECT
Name four features of the MMSE
Orientation
Concentration (Serial 7s)
Memory - short term, long term, recent
Grasp - name of monarch
Normal is 25-30, severe is less than 10
Name three frontal lobe tests
Verbal fluency and initiation
Clock drawing tests
Similarities (why are two objects similar?)
State two general managements of Dementia
Inform DVLA
Advanced planning
Describe the non pharmacological management of Dementia
Social Support
Information and education
Aromatherapy
Assistance in day to day activities
One of the pharmacological options to treat Dementia is AChesterase inhibitors. Given an example, 2 contraindications and 2 side effects
Donepazil
CI - Renal impairment, Hepatic impairment
SE - GI disturbance, Bradycardia
What is the action of Memantine?
NMDA receptor antagonist
How could you manage challenging behaviour of Dementia patients?
Short course of antipsychotics
Caution in DLB - Neuroleptic Malignant Syndrome
