Old age psychiatry Flashcards
What is the ABCD for common groups of signs/symptoms in Dementia?
Activities of Daily Living (ADLs)
Behavioural and psychiatric symptoms
Cognitive impairment
Decline - progressive disease
Cognitive features of dementia
Memory impairment (dysmnesia)
plus one or more of:
Dysphasia (communication) - expressive / receptive
Dyspraxia (inability to carry out motor skills - partial loss of the ability to co-ordinate and perform skilled, purposeful movements and gestures with normal accuracy)
Dysgnosia (not recognising objects)
Dys-executive functioning (initiation, inhibition, set-shifting, abstraction)
What are signs of poor executive functioning?
Trouble controlling emotions or impulses.
Problems with starting, organizing, planning, or completing tasks.
Trouble listening or paying attention.
Short-term memory issues.
Inability to multitask or balance tasks.
Socially inappropriate behavior.
Which screening tool can be used to determine a patient’s ability to perform daily activities?
MMSE
Score is out of 30. The lower the score the more severe the cognitive impairment
Imaging in dementia diagnosis
Tends to be clinical - from the history and presentation
You can do imaging but check to see if they’ve had any recent scans so as to avoid unnecessary stress.
If they are fit for a scan you may do CT head, CT/SPECT (if alzheimer’s is suspected) or DAT scan (good for parkinson’s or lewy body dementia) - helps to determine type of dementia or to see if there is another factor contributing to symptoms
Diagnostic pathway for Alzheimer’s dementia
Case-finding - symptom/sign of cognitive impairment is detected
Clinical assessment - history (clinical and collateral) and physical examination, Mental state exam, bloods, cognitive assessment
Differentiating AD from other causes of dementia - need to exclude delirium, depression etc
Management of AD + symptomatic treatment
4 main types of dementia in order of most common to least common
- Alzheimer’s = most common
- Vascular
- Mixed
- Lewy body dementia
More rare types of dementia
Frontotemporal dementia (picks)
Alcohol; ARBD (alcohol dementia/ Korsakoffs (thiamine deficiency))
Subcortical - Parkinson’s, Huntington’s, HIV
Prion Protein eg CJD
Important physical causes to screen for that may be causing dementia symptoms
Delirium Normal pressure hydrocephalus Subdural haemorrhage Tumours Vitamin B12 deficiency Drugs Hypercalcaemia - abdominal pain, bone pain, kidney stones, depression and confusion
Alzheimer’s disease
Early impairment of memory and executive function
Gradual progression with often unclear onset
Main features: Amyloid plaques & tau tangles, Atrophy following neuron death, reduction in Acetylcholine
Imaging of choice in Alzheimer’s
CT head or CT SPECT
Vascular dementia
Unequal distribution of deficits (not as clear cut as alzheimer’s)
Evidence of focal impairments on neuro exam
Evidence of cerebrovascular disease in PMH i.e Hypertension, hypercholesterolaemia
Step wise decline with sudden changes (go along fairly steady and then have a big dip in cognitive impairment) but small vessel disease can give gradual decline
Key features of Lew body dementia (3)
Visual hallucinations
Fluctuations - going from very lucid to very confused throughout the day
Parkinsonism - tremor, slow movements etc
Other signs which support Lew Body dementia diagnosis? (4)
They are sensitive to anti-psychotics
Reduced dopamine uptake on SPECT or PET scan
Increased falls
REM sleep disorder
Which screening tool is good for Lewy Body dementia?
DIAMOND
What is the imaging of choice for Lewy body dementia?
DAT scan - it has a sensitivity and specificity of around 85% (doesn’t pick up everyone)
Scan shows re-uptake of dopamine transporter in the head of the caudate nucleus and putamen - in DLB reuptake in the putamen is reduced - leading to a full stop sign instead of a comma
Frontotemporal Dementia (FTD) - common features?
Behavioural disorder – personality change
Can be early onset
Early emotional blunting
Speech disorder - altered output, stereotypy, echolalia, perseveration, mutism
Neuropsychology - frontal dysexecutive syndrome (Executive functions are controlled by the frontal lobes of the brain). Memory, praxis and visuospatial function are not severely impaired
Drug treatment for dementia
Acetylcholinesterase Inhibitors (AChI) for mild to moderate AD donepezil, rivastigmine, galantamine
Memantine for moderate to severe AD - NMDA receptor antagonists
Antipsychotics (eg. risperidone, quetiapine, amisulpride)
Antidepressants (eg. mirtazapine, sertraline)
Anxiolytics (eg. lorazepam)
Hypnotics (eg. zolpidem, zopiclone, clonazepam)
Anticonvulsants (eg. valproate, carbamazepine)
Which drugs are used to treat mild to moderate Alzheimer’s?
Acetylcholinesterase Inhibitors
Which drugs are used to treat moderate to severe Alzheimer’s?
Memantine
Risks associated with Acetylcholinesterase Inhibitors
N/V diarrhoea Fatigue, insomnia Muscle cramps Headaches, dizziness Syncope Breathing problems
Why might anti-psychotics be considered in dementia treatment? Why are they controversial in this group?
Psychotic symptoms - hallucinations, dellusions
Extreme agitation or aggression
There are risks associated with this treatment including increased risk of stroke, death.
Risk of harm to themselves or others has to be great before you consider it as 1st line treatment.
Lowest dose of atypical for shortest time (ideally<12 weeks)
Behavioural and Psychological Symptoms in Dementia (BPSD)
Agitation (Restlessness, Wandering)
Psychosis (Delusions, Hallucinations)
Affective (Depression, Anxiety, Lability, Hypomania,
Apathy)
Disinhibition (Aggression, Sexual)
Behaviour (Eating, toileting, dressing, Sleep-wake cycle)
5 points to consider when assessing capacity
1) Does the patient UNDERSTAND the information?
2) Does the patient RETAIN the information long enough to make a decision?
3) Can the patient COMMUNICATE the decision?
4) Can the patient WEIGH UP the information in order to make a decision?
5) Does the patient BELIEVE the information they are given?
6 Cs of capacity
Capacity Consent Compliance Coercion Certification Common sense
Normal symptoms in Grief, Mourning and Bereavement
Alarm Numbness Pining – illusions or hallucinations may occur Depression Recovery and reorganisation
Abnormal symptoms in Grief, Mourning and Bereavement
Persisted beyond 2 months Guilt Thoughts of death Worthlessness Psychomotor retardation Prolonged and marked functional impairment Psychosis
