Old age psychiatry Flashcards
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
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
What is hyperactive delirium?
Agitation, irritability, restlessness and aggression
Hallucinations and delusions prominent, may be confused with functional psychosis
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
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
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
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
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
What are some differentials for delirium?
Dementia
Mood disorders: depression or mania
Late onset schizophrenia
Dissociative disorders
Hypo/hyperthyroidism
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
What is demenia?
Syndrome of generalized decline of memory, intellect and personality without impairment of conciousness leading to functional impairment
What is the most common cause of dementia?
Alzheimer’s
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
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)
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)
What is vascular dementia due to?
Cerebrovascular disease e.g. stroke or multi-infarcts or chronic changes in the small vessels (arteriosclerosis)
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
