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Yr4 - Psych > Old Age Psychiatry > Flashcards

Old Age Psychiatry Flashcards

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1
Q

Define delirium

A

Acute, transient, global organic disorder of CNS functioning
Resulting in impaired consciousness and attention.

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2
Q

Features of hypoactive delirium

A 
40%
Lethargy
Reduced motor activity
Apathy
Sleepiness
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3
Q

Features of hyperactive delirium

A 
Agitation
Irritability
Restlessness
Aggression
Hallucinations and delusions prominent
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4
Q

Common causes of delirium

A

Hypoxia
- respiratory failure, myocardial infarction, cardiac failure, pulmonary embolism
Endocrine
- hyperthyroidism, hypothyroidism, hyperglycaemia, hypoglycaemia, Cushing’s
Infection
- pneumonia, UTI, encephalitis, meningitis
Stroke and intracranial events
- stroke, raised ICP, intracranial haemorrhage, SOL, head trauma,epilepsy, intracranial infection
Nutritional
- reduced thiamine, reduced nicotinic acid, reduced vitamin B12
Theatres
- anaesthetics, opiate analgesia, post-op complications
Other
- severe pain, sensory deprivation, relocation, sleep deprivation
Metabolic
- hypoxia, electrolyte disturbance, hepatic impairment, renal impairment
Abdominal
- faecal impaction, malnutrition, urinary retention, bladder catheterisation
Alcohol
- intoxication, withdrawal
Drugs
- benzodiazepines, opioids, anticholinergics, anti-Parkinsonism drugs, steroids

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5
Q

Risk factors for delirium

A 
Older age > 65
Multiple co-morbidities
Dementia
Physical frailty
Renal impairment
Male sex
Sensory impairment
Previous episodes
Recent surgery
Severe illness
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6
Q

Clinical features of delirium

A

Disordered thinking
- slowed, irrational, incoherent thoughts
Euphoric, fearful, depressed or angry
Language impairment
- rambling speech, repetitive, disruptive
Illusions, delusions and hallucinations
Reversal of sleep-wake pattern
- tired during day and hyper—vigilant at night
Inattention
- inability to focus, clouding of consciousness
Unaware/disoriented
- time, place or person
Memory deficits

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7
Q

ICD-10 criteria for delirium

A 
Impairment of consciousness and attention
Global disturbance in cognition
Psychomotor disturbance
Disturbance of sleep-wake cycle
Emotional disturbances
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8
Q

Management of delirium

A

Treat underlying cause
Reassurance and re-orientation
Provide appropriate environment
- quiet, well-lit side room
- encourage presence of friend or family member
- optimise sensory acuity - glasses, well-lit room, orientation aids, clock, calendar
Managing disturbed, violent of distressed behaviour
- encourage oral intake
- pay attention to continence
- verbal and non-verbal de-escalation techniques
- oral low-dose haloperidol or olanzapine
- avoid benzodiazepines - unless due to alcohol withdrawal

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9
Q

Define dementia

A

Syndrome of generalised decline in memory, intellect and personality
Without impairment of consciousness
Leading to functional impairment

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10
Q

Pathophysiology of dementia

A

Alzheimer’s
- degeneration of cholinergic neurons in the nucleus basalis leading to deficiency of acetylcholine
- microscopic - neurofibcellary tangles and beta-amyloid plaque formation
- macroscopic - cortical atrophy, widened sulci and enlarged ventricles
Vascular
- cerebrovascular disease due to stroke, multi-infarcts or arteriosclerosis
Lewy body
- abnormal deposition of Lewy body protein within neurons of the brainstem, substantia nigra and neocortex
Fronto-temporal
- degeneration of frontal and temporal lobes

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11
Q

Irreversible causes of dementia

A 
Neurodegenerative
- Alzheimer’s, fronto-temporal dementia, Pick’s disease, dementia with Lewy bodies, Parkinson’s with dementia, Huntington’s disease
Infection
- HIV, encephalitis, syphilis
Toxins
- alcohol, barbiturates, benzodiazepines
Vascular
- vascular dementia, multi-infarct dementia
Traumatic head injury
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12
Q

Reversible causes of dementia

A

Neurological
- normal pressure hydrocephalus, intracranial tumours, chronic subdural haematoma
Vitamin deficiencies
- B12, folic acid, thiamine, nicotinic acid
Endocrine
- Cushing’s syndrome, hypothyroidism

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13
Q

Prevalence of types of dementia

A

Alzheimer’s = 50%
Vascular = 25%
Dementia with Lewy bodies = 15%
Fronto-temporal = <5%

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14
Q

Classification of dementias

A 
Cortical
- AD, fronto-temporal
Subcortical
- DLB
Mixed
- vascular
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15
Q

Features of cortical dementia

A 
Severe memory loss
Normal mood
Early aphasia
Indifferent personality
Normal coordination
Apraxia
Normal motor speed
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16
Q

Features of subcortical dementia

A 
Moderate memory loss
Low mood
Can be dysarthria speech and language
Apathetic personality
Impaired coordination
Normal praxis
Slow motor speed
17
Q

Risk factors of dementia

A 
Advancing age
FH
Genetics
Down's syndrome
Low IQ
Cerebrovascular disease
Vascular risk factors
18
Q

Genes related with Alzheimer’s disease

A

Presenilin 1, Presenilin 2 and amyloid precursor protein associated with early onset AD
ApoE-4 contributes to late onset
- ApoE-2 thought to be protective

19
Q

ICD-10 classification of dementia

A 
Evidence of
- decline in memory
- decline in other cognitive abilities - characterised by deterioration in judgement and thinking
Preserved awareness of the environment 
Decline in emotional control or motivation or change in social behaviour manifested by
- emotional lability
- irritability
- apathy
- coarsening of social behaviour
Present for 6 months
20
Q

Early stages of Alzheimer’s disease

A

Memory lapses
Difficulty finding words
Forgetting names of people/places

21
Q

Disease progression of Alzheimer’s disease

A

Apraxia
Confusion
Language problems
Difficultly with executive thinking

22
Q

Later stages of Alzheimer’s disease

A 
Disorientation to time and place
Wandering 
Apathy
Incontinence
Eating problems
Depression
Agitation
23
Q

ICD-10 Criteria for Alzheimer’s disease

A

General criteria for dementia met
Insidious onset with slow deterioration
Absence of clinical evidence to suggest other cause
Absence of sudden apoplectic onset or neurological signs of focal damage
Early onset = < 65
Late onset = > 65

24
Q

Features of AD

A

Over 65
Insidious onset
Loss of memory
Disorientation to time and place
Impairment of cognitive and executive functions
- problem solving, reasoning and decision making
- visuospatial abilities - getting lost, impaired driving
- language disturbances - dysphasia
- apraxia - inability to carry out previously learned movements - dressing etc
- agnosia - impaired recognition of sensory stimuli or language disturbance
Non-cognitive symptoms
- hallucinations, delusions, depression, aggression, restlesssness

25
Q

Clinical features of vascular dementia

A

Late 60s/early 70s
Stepwise deterioration
Memory loss
Depression, apathy and personality changes - earlier than memory loss
Confusion
Neurological symptoms - spastic weakness, increased reflexes, extensor plantar response, pseudobulbar palsy

26
Q

Features of dementia with lewy bodies

A

Day to day fluctuations in cognitive performance
Recurrent visual hallucinations
Motor signs of Parkinsonism - tremor, rigidity, bradykinesia
Recurrent falls, syncope, depression
Severe sensitivity to neuroleptic drugs

27
Q

Features of fronto-temporal dementia

A

Usually 50-60s
Insidious onset
FH in 50% of cases
Early personality changes - disinhibition, apathy, restlessness
Worsening of social behaviour
Language problems
Memory preserved in early stages but insight lost

28
Q

Features of Huntington’s disease

A

Autosomal dominant
Abnormal choreiform movements of face, hands and shoulders
Gait abnormalities
Dementia presents later

29
Q

Features of normal pressure hydrocephalus

A

Onset post 70

Triad of dementia with prominent frontal lobe dysfunction, urinary incontinence and gait disturbance

30
Q

Features of Creutzfeldt-Jakob disease

A

Onset before 65
Rapid progression with death within 2 years
Disintegration of virtually all higher cerebral functions
Dementia associated with neurological signs

31
Q

Management of AD

A

First line
- supportive treatments - OT input for home safety
- environmental control measures - motions sensors
- acetylcholinesterase inhibitors
Adjuncts
- antidepressants
- antipsychotics
- management of insomnia - trazadone
- management of behavioural and psychological symptoms
- adding or switching memantine

32
Q

Management principles of dementia

A 
Cognitive enhancement - AChE inhibitors
Treat agitation
Treat low mood and insomnia
Functional support
Social support
Support for carers

Yr4 - Psych (13 decks)

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