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
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
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
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
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
