Old Age Psychiatry Flashcards
Old Age Psychiatry - what people do they care for?
Care of people over 65 mental health
Few under 65 if confirmed diagnosis of dementia
how common are the different mental illnesses in the community and the hospitals?
Mental illness common in 65+ population
Biggest risk factor for dementia is age
Most higher prevalence in hospital
A typical 500 bed district general hospital - what kind of patients are there?
In an average day:
◦ 330 beds will be occupied by older people.
◦ 220 will have a mental disorder
◦ 96 will have depression
◦ 66 will have delirium
◦ 102 will have dementia
◦ 23 will have other major mental health problems
2/3 of beds occupied by old people and 2/3 of those have some sort of mental disorder
If someone has a coexisting mental illness then length of stay can _______ (first photo)
Survival _________ in patients with mental illness (second photo)
increase
decreased
ABCD of Dementia: Dementia is a Clinical syndrome
what is the ABCD
A for Activities of Daily Living (ADLs)
B for Behavioural and Psychiatric Symptoms of Dementia (BPSD)
C for Cognitive Impairment
D for Decline
Progressive syndrome - decline in both cognitive function and functional actives of daily living
how does someone present with dementia, how is the diagnosis made and what is done for them?
6 months duration, usually progressive
Diagnosis based on Hx and collateral
PMHx & Medication (particularly anti cholinergics)
Cognitive testing (MMSE or MOCA) with emphasis on relevant lobes - Neuropsychology
Physical examination & bloods
Supportive evidence from brain imaging
Diagnosis deferred in delirium (If co existing delirium then don’t give diagnosis of dementia as may be causing it)
what are the Cognitive features of Dementia?
•Memory (dysmnesia) (Memory most common feature – may be short or long term)
Plus one or more of:
- dysphasia (communication) - expressive, Receptive (struggling to understand language)
- dyspraxia (inability to carry out motor skills)
- dysgnosia (not recognising objects)
- dysexecutive functioning (initiation, inhibition, set-shifting, abstraction) (planning and problem solving skills)
Functional impairment:
What are Important areas to ask about?
The biggest risks?
Driving
Cooking – how they prepare their meals
Money and finance, pin numbers
Personal care – dressing and washing clothes
And dependants or pets and are they caring for them as they should be
Managing with phone
Keeps house tidy
Able to use technology (or have they never been able to do it)
Medication – responsible for taking meds themselves and if they are taking it or taking it more regularly as forgot they took it
Cars - Fitness to Drive
Dementia or Organic Brain Syndrome - what is done when someone has this?
notify DVLA at diagnosis
if early dementia license may be yearly (reviewed every year)
“those with poor short term memory, disorientation or lack of insight should almost certainly not drive”
Often tell them to stop driving and don’t take news well
what is the MMSE?
Test of cognition
Do in clinic
Marked out of 30
a 30-point questionnaire that is used extensively in clinical and research settings to measure cognitive impairment. It is commonly used in medicine and allied health to screen for dementia
what is the MOCA?
MOCA is another basic tests of cognition
Also marked out of 30
Often score higher on MMSE than MOCA
The MoCA is a cognitive screening test designed to assist Health Professionals in the detection of mild cognitive impairment and Alzheimer’s disease
how does MMSE scores correlate with ability to perform daily activities?
Changes in test results can correlate with change in function
do you use imaging in dementia?
Consider most appropriate for patient
Do they need imaging?
CT
CT/SPECT
DAT scan
Have they had scan in recent years due to different reason and can you look at that
Dementia often a clinical diagnosis and you often get enough information for them
Think are they fit for a scan, depends on what type of scan aswell as some are claustrophobic scans
SPEC if you think its Alzheimer dementia
DAT scans for Parkinson’s and lewy body dementias
Diagnosing AD in primary care
A systematic approach summary
A structured and systematic approach is required to ensure the early diagnosis and management of AD. The diagnostic process includes what?
Case-finding
Clinical assessment
Differentiating AD from other causes of dementia
Management of AD
what is the aetiology of dementia?
Alzheimer’s dementia – 62%
Vascular dementia – 17%
Mixed Dementia – 10%
Lewy body dementia – 4%
Most common cause is Alzheimer’s
Mixed is when 2 or more pathologies contributing to dementia
aetiology of dementia - what are some Rarer types of dementia?
Frontotemporal (Picks) (behavioural, PNFA: progressive non fluent aphasia, semantic)
Alcohol; ARBD (alcohol dementia/ Korsakoffs (thiamine deficiency)) – more common in u65 age group
Subcortical - Parkinson’s, Huntington’s, HIV
Prion Protein eg CJD
aetiology - what are some reversible causes of dementia?
Important physical causes to screen for
◦Delirium
◦Normal pressure hydrocephalus
◦Subdural haemorrhage
◦Tumours
◦Vitamin B12 deficiency
◦Hypothyroidism
◦Hypercalcaemia - abdominal pain, bone pain, kidney stones, depression and confusion
◦Alcohol misuse
◦Neurosyphilis
◦Drugs
No matter what cause of dement , the course is ______
similar
Case Study 1:
78 year old woman referred by GP with 3 year history of gradual and progressive deterioration in ‘memory’
On cognitive testing she has some dysmnesia (poor short term recall) and dysexecutive dysfunction
Clear functional impairment – reliant on daughter
No focal neurological signs
No history of vascular disease or risk factors
Diagnosis? Would you order imaging?
Alzheimers disease
how does alzheimers present?
Presentation - Early impairment of memory and executive function
Gradual progression with often unclear onset (Insidious onset – comes slowly)
Risk of Alzheimer’s dementia increases with age: 1% at age 60, 5% at age 65, doubles every 5 years, 40% of those aged 85
Other risk factors include family history, Down’s syndrome and vascular risk factors
what are the main features of alzheimers disease?
Amyloid plaques & tau tangles (protiens)
Atrophy following neuron death
Reduction in (availability of) Acetylcholine (in the brain)
Alzheimer’s = more temporal
CT = ???
SPECT = ???
structural or functional?
CT = structural
SPECT = functional
how does Vascular Dementia present?
Unequal distribution of deficits (Much more patchy deficits)
Evidence of focal impairments on neuro exam
Evidence of cerebrovascular disease - PMHx (from the history, there is some sort of past medical history of hypertension, hypoglycaemia and other types of vascular disease)
Step wise decline with sudden changes
Small vessel disease can give gradual decline (can give a picture slightly more like Alzheimer’s with a gradual decline of cognition and function)
Case Study 2:
74 year old woman referred by GP with subtle personality changes, lack of motivation and progressive apathy
On cognitive testing she has some executive dysfunction but intact memory
Reports constant dull headache (much worse in morning)
No focal neurological signs
Diagnosis? Imaging?
Obvious heavily calcified lesion in left frontal region suggestive of meningioma
Referred to neurosurgeons who resected meningioma
After period of recovery cognition and personality revovered
Not a typical dementia presentation, short history of symptoms and morning headache is a red flag
Defo imaging for this person
Case 3:
80 year old man referred by GP with ~ 9 month history confusion that fluctuates throughout the day
Wife reports increased movement and shouting in his sleep. He is often napping during the day
He reports seeing animals in the house and faces in the wallpaper
Recent onset of tremor in right hand
Worsening mobility
Lewy body dementia
what are the key features of Lewy body dementia?
Visual hallucinations
Fluctuations
Parkinsonism
So if somebody’s got Parkinson’s and it’s established in the developed dementia, it’s Parkinson’s dementia
If they’ve developed Parkinsonism after developing other features, dementia, it’s more likely to be Lewy body dementia.
how do you manage Lewy body dementia?
Supportive:
◦Sensitivity to antipsychotics
◦Reduced dopamine uptake on SPECT or PET scan
◦Increased falls
◦REM sleep disorder
DATScan in DLB - what should it look like?
Sensitivity and specificity of around 85%
The DATScan on a normal or AD patient will show normal re-uptake of the dopamine transporter in the head of the caudate nucleus and putamen in the shape of a ‘comma’, whereas in DLB, re-uptake in the putamen is reduced, leading to the ‘full-stop’ sign
A DAT scan as commonly done for Lewy body or Parkinsonism
Comma shape is normal on left
Case Study 4:
50 year old man presents to clinic. Worked as an IT technician for last 10 years
Gradual change in his behaviour over last 2 years. Stopped taking care of his appearance and personal hygiene
Clear personality change. Apathetic and withdrawn,
Used to be tidy but house now chaotic
Diagnosis? Imaging?
Axial MRI images shows cerebral atrophy that is more pronounced in the frontal and temporal regions
Note the difference in the gyro thickness and size of the sulci between the frontotemporal region and the parietal/occipital region
Younger in age and clear change in frontal lobe (looks after personality)
Get scan as young age
Pick’s disease is the older name for frontotemporal dementia a behavioural variant, you’ll still commonly see it be used.
Clear evidence of atrophy
Frontotemporal Dementia (FTD) - when is the onset?
Can be early onset
what are the symptoms and changes seen in Frontotemporal Dementia (FTD)?
Behavioural disorder – personality change
Early emotional blunting
Speech disorder - altered output, stereotypy, echolalia, perseveration, mutism
Neuropsychology - frontal dysexecutive syndrome. Memory, praxis and visuospatial function not severely impaired (Often score well on cognitive testing so neuropsychology testing good for detecting)
Neurological signs commonly absent early; parkinsonism later; MND in a few; autonomic; incontinence; primitive reflexessyndrome. Memory, praxis and visuospatial function not severely impaired
what imaging changes are seen in FTD?
abnormalities in frontotemporal lobes
Regardless of the aetiology of the dementia, there is potential for people to develop behavioural and psychological symptoms of dementia
what are some Behavioural and Psychological Symptoms seen in Dementia
Agitation (Restlessness, Wandering)
Psychosis (Delusions, Hallucinations)
Affective (Depression, Anxiety, Lability, Hypomania, Apathy)
Disinhibition (Aggression, Sexual)
Behaviour (Eating, toileting, dressing, Sleep-wake cycle)
what are the drug treatments for dementia?
Acetylcholinesterase Inhibitors (AChI) for mild to moderate AD - donepezil, rivastigmine, galantamine
Memantine for moderate to severe AD
Antipsychotics (eg. risperidone, quetiapine, amisulpride)
Antidepressants (eg. mirtazapine, sertraline)
Anxiolytics (eg. lorazepam)
Hypnotics (eg. zolpidem, zopiclone, clonazepam)
Anticonvulsants (eg. valproate, carbamazepine)
Acetylcholinesterase Inhibitors - what are they and what do they do?
Donepezil, Galantamine, Rivastigmine (All quite similar)
Similar clinical effects on MMSE & ADAS COG
10 RCTs showed improved cog function, ADLs & behaviour however small Rx effects
Delays time to institutionalisation
Effect of increasing acetylcholine For Alzheimers & LBD
it increases the availability of acetylcholine in the brain. And so they’re not reversing disease, but they are slowing down progression of impairment and function and cognition
what are the risks of Acetylcholinesterase Inhibitors?
Nausea, vomiting, diarrhoea
Fatigue, insomnia
Muscle cramps
Headaches, dizziness
Syncope
Breathing problems
The serious things to consider as contraindicated and those with severe respiratory disease
whats the problem with Antipsychotics?
controversial
I guess the main reason that they’re quite controversial as they can have significant side effects and be quite dangerous in this population
Increased risk of stroke and death
Pharmacological:
what is the Guidance on Anti Psychotic use?
Not first line except where extreme risk
Detailed assessment of BPSD including ABC
Address treatable causes
Symptoms primarily a problem for patient or carers
High rate of spontaneous recovery
Psychological approaches including structured activity
Discussion regarding best interests (with family members and next of kin
Lowest dose of atypical for shortest time (ideally <12 weeks)
Monthly review recommended
how can Non pharmacological approach be used to help dementia?
- Other causes of distress
- ABC approach
- Communication - With patient and family
- Any form of Distraction
what is capacity?
Capacity is the ability to understand information relevant to a decision or action, and to appreciate the reasonably foreseeable consequences of not taking action or decision
what are 5 points to consider when deciding if someone has capacity of not?
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?
It’s retaining that information long enough to make the decision. Doesn’t necessarily mean they will retain that decision. But often if the patient is not retaining the decision, one way around is to do the assessment a couple of different times And if they’re giving you a consistent decision that can be considered capacity
Assessing Capacity- What are the Key Points?
1) A patient is deemed to have capacity unless proven otherwise
2) A patient should be supported to make a decision
3) A person can not be deemed to incapable if their decision is eccentric or unwise
4) Anything done for the patient must be in their best interest
5) Always use the least restrictive option (Cant live on their own so would you choose sheltered housing or a locked nursing home – choose sheltered housing as its least restrictive)
6) Capacity should be assessed on the topic of question (Capacity for one question but not another)
7) Patient’s should be assessed at their ‘peak time’
8) Speak to family to get historic views? Advanced statement
what are the 6 Cs of capacity?
Capacity
Consent
Compliance
Coercion
Certification (Adults with incapacity act or mental health act)
Common sense (doing things in the patients best interest)
Power of Attorney - what is their role?
Finance - Usually easier to retain capacity re granting this than for welfare
Welfare - Big issues re powers to have you reside
Are the powers even being used?
Does it have to be ‘activated’ - Common sense i.e. ‘best interests’, letter
Are the powers being misused? (If it’s misused or inappropriately used at may be revoked and can be quite a messy situation and usually involves local authority, legal team)
Who has the powers?
Who doesn’t have the powers?
Revocation of power of attorney
Public Guardian’s Office (registered with this to be legal)
Granted by someone who has capacity to use when they lose capacity for whatever reason
Only used when person doesn’t have capacity
who can get Guardianship and when does it?
If you’ve missed the boat to get power of attorney, so it’s not been set up, not been signed before, you’ve lost capacity - The option is guardianship. I would really stress as guardianship is far more of a hassle and more expensive, takes longer as goes through courts, don’t get to decide who makes decision for you
Often it’s family or friends that are applying for guardianship, but sometimes that’s the local authority if there’s not an appropriate alternative
what is guardianship responsible for?
Finance
Welfare
what is required in order to get guardianship?
They lack capacity to grant POA
Two medical certificates - GP and Psychiatrist
Detailed report from MHO (social worker):
- Will take into account family and those nominated in the application
- Is it needed?
- Is it agreed?
- Who will be the guardian?
functional illness
What else apart from dementia?
Depressive symptoms 15%
Depressive illness 3%
Anxiety disorders - generalised anxiety, panic disorder, agoraphobia, PTSD
Mania (Bipolar disorder)
Schizophrenia (May be people diagnosed with major mental illness like bipolar or schizophrenia in their younger years and graduated up into the older age group. Others are those developed the disorder later in life)
Late onset Schizophrenia Like Psychosis
Alcohol problems
Suicide
Medicolegal (power of attorney, guadinship, capacity type assessments)
(Delirium) – this is big part of our job
what is the prevelance, clinical features, aetiology, management and prognosis of depression in the old age population?
Can present different in older population
More common in residential care
Same genetic factors
First line would be antidepressants – consider mirtazapine as it makes people drowsey and increases appetite and actually these are quite helpful as many older people present with sleeping difficulties and poor appetite
Grief, Mourning and Bereavement:
normal is:
- Alarm
- Numbness
- Pining – illusions or hallucinations may occur
- Depression
- Recovery and reorganisation
What is abnormal?
- Persisted beyond 2 months
- Guilt
- Thoughts of death
- Worthlessness
- Psychomotor retardation
- Prolonged and marked functional impairment
- Psychosis
what is suicide like in the elderly
Same rate as for under 25 age group, Half the rate of other age groups
Males more than females
Most are depressed
DSH is rare in the elderly
what are some reasons for suicide in the elderly?
loneliness
widowed
ill health
chronic pain
recent life events
few seeing psychiatrist
what is the prevelance, clinical features, aetiology, management and prognosis of late onset schizophrenia like psychosis?
Management hard as often lack insight
May need mental health act
Antipsychotics
Prognosis variable
