Old age psychiatry Flashcards by sofia littlejohn

What is delirium?

Acute, transient, organic disorder of CNS functioning resulting in impaired conciousness and attention

May be hypoactive, hyperactive and mixed depending on presentation

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What are the features of hypoactive dilirium?

Lethargy

Decreased motor activity

Most common type of delirium but often goes unrecognised

Can be confused with depression

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What is hyperactive delirium?

Agitation, irritability, restlessness and aggression

Hallucinations and delusions prominent, may be confused with functional psychosis

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What are the causes of delirium?

HE IS NOT MAD

Hypoxia = resp failure, MI, PE

Endocrine = hyper/hypothyroid, hyper/hypoglycaemia, Cushing’s

Infection = Pneumonia, UTI, encephalitis, meningitis

Stroke = raised ICP, space-occupying lesions, head trauma

Nutritional = low thiamine, low nicotinic acit, low vit B12

Others = Severe pain, sensory deprivation (taking spectacles / hearing aids), sleep deprivation

Theatre (post-op) = anaesthetic, opiates

Metabolic = hepatic / renal impairment

Abdo = faecal impactation, malnutrition, urinary retention

Alcohol = intoxication / withdrawal

Drugs = benzos, opiods, anticholinergics

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What are some risk factors for delerium?

Older age > 65

Dementia

Renal impairment

Sensory impairment

Recent surgery

Multiple co-morbidities

Physical frailty

Male sex

Previous episodes

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What are the features of delirium?

Acute onset and fluctuating course

Disordered thinking
Emotional disturbances
Rambling speech, repetitive
Illusions / delusions / hallucinations
Reversal of sleep / wake patterns
Inattention
Unaware / disorientated
Memory deficits

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How is delirium distinguished from dementia?

In delirium sleep-wake pattern is distrupted, attention is markedly reduced, lasts for hours-weeks, delusions are fleeting, course is fluctuating, consiousness level is impaired, hallucinations are common, onset is acute

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What are the investigations for delirium?

Urinalysis (UTI)
FBC (infection)
U&E (electrolyte disturbance)
LFTs (alcoholism, liver disease)
Calcium (hypercalcaemia)
Glucose (hypo/hyperglycaemia)
CRP (infection / inflammation)
TFTs (hyperthyroidism)
B12 / folate / ferritin (nutritional deficiencies)
ECG (cardiac abnormalities, ACS)
CXR (chest infection)
Blood cultures (sepsis)
ABG (hypoxia)
CT head (head injury, CVA)
Lumbar puncture (meningitis)
EEG (epilepsy)
Questionnaire = AMT, CAM or MMSE

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What are some differentials for delirium?

Dementia

Mood disorders: depression or mania

Late onset schizophrenia

Dissociative disorders

Hypo/hyperthyroidism

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What is the management of delirium?

- Treat underlying cause (infection, electrolyte disturbance, offending drugs, laxatives for faecal impactation)

- Reassurance and re-orientation (reminded of time, place, day and date regularly)

- Provide appropriate environment (quite, well-lit side room, consistency in care, encourage presence of friend / family member, give glasses, hearing aids)

- Oral low-dose haloperidol or olanzapine for distressed patients - avoid benzos unless delerium due to alcohol withdrawal

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What is demenia?

Syndrome of generalized decline of memory, intellect and personality without impairment of conciousness leading to functional impairment

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What is the most common cause of dementia?

Alzheimer’s

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What happens in Alzheimer’s disease?

What are the microscopic and macroscopic changes?

Degeneration of cholinergic neurons in the nucleus basalis of Meynert leading to a deficiency of acetylcholine

Microscopic = neurofibrillary tangles (intracellularly) and B-amyloid plaque formation (extracellularly)

Macroscopic = cortical atrophy (commpnly hippocampal), widened sulci and enlarged ventricles

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What are the irreversible causes of dementia in order of prevalence?

- Alzheimer’s

- Vascular

- Dementia with Lewy bodies

- Fronto-temporal dementia

- Other causes (Pick’s disease, Parkinsons, Huntingtons, HIV, encephalitis, syphilis, CJD, alcohol, traumatic head injury)

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What are the reversible causes of dementia?

- Normal pressure hydrocephalus

Intracranial tumours
Vitamin deficiencies (B12, folic acid, thiamine, nicotinic acid - pellegra)
Endocrine (cushing’s, hypothyroidism)

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What is vascular dementia due to?

Cerebrovascular disease e.g. stroke or multi-infarcts or chronic changes in the small vessels (arteriosclerosis)

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What is Lewy bosy dementia due to?

Abnormal deposition of a protein (lewy body) within neurons of the brainstem, substantia nigra and neocortex

What happens in fronto-temporal dementia, give an example?

Atrophy of the frontal and temporal lobes

Pick’s disease (protein tangles - Pick’s bodies - are seen)

Name some risk factors for Alzheimer’s disease?

Advancing age
FH
Down’s syndrome (pre-senile AD)
Low IQ
CVD (for vascular dementia)

What are the features of dementia?

My cat loves eating pigeons

Memory

Cognition

Language

Executive functioning

Personality

Present for 6 months

What are the other features of AD?

Loss of memory
Disorentation to time and place
Impairment of: problem solving, abstract thinking, reasoning, decision making
Dysphagia
Apraxia (inability to carry out previously learned purposeful movements)

What are the features of vascular dementia?

Stepwise deterioration

Memory loss
Emotional and personality changes
Confusion is common

What are the features of Demenia with Lewy bodies?

Day to day variations in cognitive performance
Recurrent visual hallucinations
Parkinsonism (tremor, rigidity, bradykinesia)
Recurrent falls, syncopy and depression

What are the features of Fronto-temporal dementia (including Pick’s disease)?

Disinhibition (reduced control over ones behaviour)
Apathy/restlessness
Worsening of social behaviour
Language problems
Presents between ages of 50 and 60
Memory is preserved in early cases

What are the features of Huntington's disease?

- **Autosomal dominant** - **Abnormal choreiform movement** of face, hands and shoulders and gait abnormalities - Dementia presents later

How does normal pressure hydrocephalus present?

* **Demenia** * **Urinary incontinence** * **Wide gait**

How does Creutzfeldt-Jakob disease (CJD) present?

- Onset before 65 years old - Rapid progression with death within 2 years - Disintegreation of all **higher cerebral function**

What is Charles-Bonnet syndrome? What are the risk factors?

**Visual hallucinations** (may also be auditory) associated with eye disease (most commonly faces, children and wild animals) Advanced age, peripheral visual impairment, social isolation, sensory deprivation

What are the routine investigations for dementia?

**FBC** (infection, anaemia) **CRP** (infection, inflammation) **U&Es** (renal disease) **Calcium** (hypercalcaemia) **LFTs** (alcoholic liver disease) **Glucose** (hypoglycaemia) **Vit B12 and folate** (nutritional deficiences) **TFTs** (hypothyroidism)

What further testing may be required for dementia (guided by clinical assessment)?

**Urine dipstick** (UTI) **CXR** (pneumonia, lung tumour) **Syphilis serology and HIV testing** (atypical features or special risks) **Brain imaging** if \<60 years old, sudden decline, focal CNS signs (space occupying lesions e.g. subdural haematoma, abscess and tumour) **ECG** (if CVD suspected) **EEG** (if fronto-temporal dementia or CJD suspected) **Genetic testing** (huntington's and familial dementia)

What are some differentials for dementia?

- Normal ageing and mild cognitive impairment - Delerium - Trauma e.g. stroke - Depression ('pesudodementia') - Late onset schizophrenia - Learning difficulty - Substance misuse

What factors support a diagnosis of **depression over dementia**?

**Depression** = short history, rapid onset, weight loss, sleep disturbance, patient worried about poor memory, reluctance to take tests, global memory loss (dementia causes more recent memory loss)

What is important to ask in a dementia history?

Functional capacity: - Dressing - Continence - Self-care - Shopping / housework - Financial affairs - Safety in the home - Ability to cook - Nutrition

What are some **frontal lobe tests**?

**Verbal fluency**: say as many words beginning with S in a minute (fewer than 10 is abnormal) **Cognitive estimates**: educated guesses e.g. age of oldest person in the country **Clock-drawing**: draw a clock with the numbers and make it show ten past 5 **Similarities**: how are a banana and an orange similar (both fruits)

What are some general points in the management of dementia?

Patients must contact DVLA (may be able to still drive) Early discussions around advanced planning (e.g. lasting power of attorney, preffered place of care) Vascular demential is modifiable and preventable by targeting cardiovascualr risk factors

What is the **first line** and **adjunctive** treatment of dementia?

**First line** = supportive (OT input for home safety evaluation) to **promote independence**, acetylcholinesterase inhibitors **Adjuncts** = antidepressants, antipsychotics, management of insomnia (e.g. trazadone)

Give 3 examples of **acetylcholinesterase inhibitors** (used for Alzheimer's)

Donepezil Galatamine Rivastigmine

What can be used for severe Alzheimer's?

Memantine (NMDA receptor antagonist)

When should **antipsychotics** not be used in dementia?

Dementia with Lewy bodies (causes severe adverse effects)

How do acetylcholinesterase inhibitors work?

Centrally acting agents which work by **compensating** for depletion os acetylcholine in the **cerebral cortex** and **hippocampus** in AD Cautioned in arrythmias (e.g. sick sinus syndrome), peptic ulcer disease, asthma and COPD