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
