Old Age Psychiatry Flashcards
Define delirium
Acute, transient, global organic disorder of CNS functioning
Resulting in impaired consciousness and attention.
Features of hypoactive delirium
40% Lethargy Reduced motor activity Apathy Sleepiness
Features of hyperactive delirium
Agitation Irritability Restlessness Aggression Hallucinations and delusions prominent
Common causes of delirium
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
Risk factors for delirium
Older age > 65 Multiple co-morbidities Dementia Physical frailty Renal impairment Male sex Sensory impairment Previous episodes Recent surgery Severe illness
Clinical features of delirium
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
ICD-10 criteria for delirium
Impairment of consciousness and attention Global disturbance in cognition Psychomotor disturbance Disturbance of sleep-wake cycle Emotional disturbances
Management of delirium
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
Define dementia
Syndrome of generalised decline in memory, intellect and personality
Without impairment of consciousness
Leading to functional impairment
Pathophysiology of dementia
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
Irreversible causes of dementia
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
Reversible causes of dementia
Neurological
- normal pressure hydrocephalus, intracranial tumours, chronic subdural haematoma
Vitamin deficiencies
- B12, folic acid, thiamine, nicotinic acid
Endocrine
- Cushing’s syndrome, hypothyroidism
Prevalence of types of dementia
Alzheimer’s = 50%
Vascular = 25%
Dementia with Lewy bodies = 15%
Fronto-temporal = <5%
Classification of dementias
Cortical - AD, fronto-temporal Subcortical - DLB Mixed - vascular
Features of cortical dementia
Severe memory loss Normal mood Early aphasia Indifferent personality Normal coordination Apraxia Normal motor speed
Features of subcortical dementia
Moderate memory loss Low mood Can be dysarthria speech and language Apathetic personality Impaired coordination Normal praxis Slow motor speed
Risk factors of dementia
Advancing age FH Genetics Down's syndrome Low IQ Cerebrovascular disease Vascular risk factors
Genes related with Alzheimer’s disease
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
ICD-10 classification of dementia
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
Early stages of Alzheimer’s disease
Memory lapses
Difficulty finding words
Forgetting names of people/places
Disease progression of Alzheimer’s disease
Apraxia
Confusion
Language problems
Difficultly with executive thinking
Later stages of Alzheimer’s disease
Disorientation to time and place Wandering Apathy Incontinence Eating problems Depression Agitation
ICD-10 Criteria for Alzheimer’s disease
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
Features of AD
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
Clinical features of vascular dementia
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
Features of dementia with lewy bodies
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
Features of fronto-temporal dementia
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
Features of Huntington’s disease
Autosomal dominant
Abnormal choreiform movements of face, hands and shoulders
Gait abnormalities
Dementia presents later
Features of normal pressure hydrocephalus
Onset post 70
Triad of dementia with prominent frontal lobe dysfunction, urinary incontinence and gait disturbance
Features of Creutzfeldt-Jakob disease
Onset before 65
Rapid progression with death within 2 years
Disintegration of virtually all higher cerebral functions
Dementia associated with neurological signs
Management of AD
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
Management principles of dementia
Cognitive enhancement - AChE inhibitors Treat agitation Treat low mood and insomnia Functional support Social support Support for carers
