old age psychiatry Flashcards
age
> 65
some under 65 if confirmed dementia
ABCD of dementia
A: activities of daily living (ADLs)
B: behavioural + psychiatric symptoms of dementia
C: cognitive impairment
D: decline
cognitive features of dementia
dysmnesia
+ 1+ of:
- dysphasia (communication): expressive, receptive
- dyspraxia - inability to carry out motor skills
- dysgonia - not recognising objects
- dysexecutive functioning (initiation, inhibition, set-shifting, abstraction)
expressive dysphasia
word finding difficulty
struggle to get through sentences
receptive dysphasia
struggle to understand language
dementia: functional impairment
ask about daily routine; driving using phone toileting/showering cooking housework/cleaning taking medication manage finances
fitness to drive
dementia or organic brain syndrome
- notify DVLA at diagnosis
- if early dementia license may be yearly
- those with poor short term memory, disorientation or lack insight should almost certainly not drive
dementia imaging
consider most approp for pt, do they need imaging?
CT
CT/SPECT
DAT scan
cognitive tests can do in clinic
mini-mental state examination (MMSE)
montreal cognitive assessment (MOCA)
causes/types of dementia
alzeimer's vascular dementia mixed demtia lewy body dementia alcohol related brain damage parkinson's, Huntington's, HIV
reversible causes of dementia: physical things to screen for
delirium normal pressure hydrocephalus subdural haemorrhage tumours VitB12 deficiency hypothyroidism hypercalcaemia alcohol misuse neurosyphilis drugs
course of dementia
initially present with symptoms then diganosis
as progress likely to lose independence and need support (fam, care setting)
then behavioural problems and then thinking about nursing home
life limiting and palliative disease - will die of it
general alzheimer’s presentation
early impairment of memory and executive function
gradual onset with often unclear onset
pathological features of alzeiher’s i.e. what would u find on autopsy
amyloid plaques and tau tangles
atrophy of brain following neuron death
reduction in acetylcholine in brain
risk factors alziehmer’s
inc age
family history
down syndrome
vascular risk factors
vascular dementia features
unequal distribution of deficits
focal impairments on neuro exam
PMHx cerebrovascular disease
step wise decline with sudden changes
small vessel disease can give gradual decline
key features of lewy body dementia
visual hallucinations fluctuations - lucid, confused then back again parkinsonism REM sleep disorder falls sensitive to anti-psychotics
what type of scan is usually done when Lewy body dementia suspected
DAT scan
frontotemporal dementia key features
behavioural - personality change
early onset
early emotional blunting
speech disoder: altered output, preservation, echolalia
frontotemporal dementia neuropsychology
frontal dysexecutive syndrome
memory, praxis and visuospatial function not severely impaired
frontotemporal dementia neuroimaging
abnormalities in frontotemporal lobes
behavioural and psychological symptoms in dementia
agitation - restlessness, wandering
psychosis - delusions, hallucinations
affective - depression, anxiety, hypomania, apathy
disinhibition - aggression, sexual
behaviour - eating, toileting, dressing, sleep-wake cycle
drug treatments of dementia
acetylcholinesterase inhibitors (mild-moderate AD + lewy body)
memantine (mod-severe AD)
antipsychotics antidepressants anxiolytics hypnotics anticonvulsants
acetylecholinesterase inhibitors
increase amount of acetylcholine in the brain
slowing down progression of functional + cognitive impairment
acetylecholinesterase inhibitors: side effetcs
nausea, vomot, diarrhoea fatigue, insomnia muscle cramps headache dizziness syncope breathing probs
dementia mangement” non-pharmalogical
other causes of distress
ABC approach
communication
any form of distraction
capacity
ability to understand info relevant to a decision or action
and to appreciate the reasonably foreseeable consequences of not taking action or decision
5 points to consider when it comes to capacity
- does pt understand info?
- does pt retain the info long enough to make decision?
- can pt communicate decision?
- can pt weigh up the info in order to make decision?
- does pt believe the info they are given?
key points when assessing capacity (8 of them)
- patient deemed to have capacity unless proven otherwise
- patient should be supported to make decision
- person cannot be deemed to incapable if decision is eccentric or unwise
- anything done for pt must be done in best interest
- use least restrictive option
- capacity should be assessed on topic of question
- pt should be assessed at their ‘peak time’
- speak to fam to get historic veiws
6Cs of capacity
capacity consent compliance coercion certification common sense
functional illness in >65
basically anything that isn’t dementia
depressive symptoms/illness anxiety disorders mania and BAD schizophrenia alcohol problems
(delirium)
presentation of depression in older population
less likely to present with depressed mood, suicidal wishes etc
more likely: insomnia, hypochondriasis, agitation, completed suicide
psychosocial factors that may contribute to old age depression
loss; health, wealth (shit pension), spouse, work, home (e.g. moving to nursing home)
treatment of depression in older people
- antidepressants e.g. sertraline
- CBT
- ECT in severe cases
most community cases not treated
late onset schizophrenia like psychosis: features
spectrum from circumscribed persecutory delusions to full schizophrenia-like psychosis
late onset schizophrenia like psychosis: aetiology
sensory loss
social isolation
genetic? minor abnormalities
late onset schizophrenia like psychosis: management
often need compulsory admission
neuroleptics
increasing social contact
