Old Age Psychiatry -Mentor &more 1 Flashcards
1
Q
What is the estimated risk of developing Alzheimer’s disease at age 60?
A
1%
The risk doubles every 5 years to reach 30% to 50% by age 85.
2
Q
What are recognized risk factors for the development of Alzheimer’s disease?
A
- Age
- Family history
- Smoking
- Head trauma
- Hypertension
- Heart disease
- Diabetes
- CVA
- High cholesterol
- Lower educational level
- Female gender
Aluminium is believed NOT to be a cause of Alzheimer’s disease.
3
Q
What factors are associated with a decreased risk of Alzheimer’s disease?
A
- Statin use
- Light-to-moderate alcohol consumption
- Compliance with a Mediterranean diet
- Physically and cognitively stimulating activities
4
Q
What is SPECT imaging used for in relation to Alzheimer’s disease?
A
Differentiating between patients with Alzheimer’s and healthy older subjects
It is also useful for distinguishing Alzheimer’s disease from Lewy body dementia.
5
Q
What is the response rate of antidepressants in the elderly compared to younger adults?
A
Similar
Factors such as physical illness and baseline anxiety affect prognosis.
6
Q
Which antidepressant is commonly suggested to start with for elderly patients?
A
SSRI (Sertraline)
If no response, consider another SSRI or a newer generation antidepressant.
7
Q
What are the risks associated with SSRIs in elderly patients?
A
- Increased risk of gastrointestinal bleeds
- Increased risk of hyponatraemia
- Increased risk of falls
8
Q
What condition does CADASIL refer to?
A
Cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy
9
Q
What is the typical age of onset for CADASIL?
A
Mean age of 35-40
10
Q
What characterizes Charles Bonnet syndrome?
A
Persistent or recurrent complex visual hallucinations occurring in clear consciousness
11
Q
What are the common risk factors for Charles Bonnet syndrome?
A
- Advanced age
- Peripheral visual impairment
- Social isolation
- Sensory deprivation
- Early cognitive impairment
12
Q
What is Diogenes syndrome characterized by?
A
- Extreme neglected physical state
- Social isolation
- Domestic squalor
- Tendency to hoard excessively
13
Q
What distinguishes delirium from dementia in terms of onset?
A
Delirium has a brief onset, while dementia has a gradual onset.
14
Q
What are the three subtypes of delirium?
A
- Hypoactive
- Hyperactive
- Mixed
15
Q
What is the first-choice pharmacological treatment for delirium according to NICE guidelines?
A
Haloperidol
16
Q
What is Lewy body dementia characterized by?
A
- Progressive cognitive impairment
- Parkinsonism
- Visual hallucinations
17
Q
What is the sensitivity and specificity of SPECT in diagnosing Lewy body dementia?
A
Sensitivity: 90%, Specificity: 100%
18
Q
What is the prevalence of CADASIL?
A
About 2 per 100,000
19
Q
True or False: Antipsychotic drugs are effective in treating Charles Bonnet syndrome.
A
False
Antipsychotic drugs are largely ineffective.
20
Q
Fill in the blank: The most effective treatment for Charles Bonnet syndrome is _______.
A
Reversal of the visual impairment
21
Q
What is a common presenting feature of delirium?
A
Impairment in attention
22
Q
What is a major precipitating factor for Diogenes syndrome?
A
Loss of a close relative who was caring for the patient
23
Q
What is currently commercially known as a DaTscan?
A
Dopaminergic iodine-123-radiolabelled 2-carbomethoxy-3-(4-iodophenyl)-N-(3-fluoropropyl) nortropane (123-I FP-CIT)
It is used as the radioisotope.
24
Q
What is the sensitivity and specificity of SPECT in diagnosing Lewy body dementia?
A
Sensitivity is around 90% and specificity is 100%.
25
What are the treatment challenges in managing Lewy body dementia (LBD)?
Challenges include cognitive and motor symptoms, fluctuations in attention and alertness, visual hallucinations, and medication sensitivity.
26
What is Rivastigmine and its primary function?
Rivastigmine is a cholinesterase inhibitor that increases levels of acetylcholine in the brain.
27
What does evidence suggest about Rivastigmine's effectiveness in LBD?
Some studies suggest it can improve cognitive, psychiatric, and global symptoms despite limited evidence.
28
What are common side effects of Rivastigmine?
* Nausea
* Vomiting
* Upset stomach
* Increased bowel movement frequency
29
What is the conclusion regarding Rivastigmine's role in treating LBD?
While evidence is sparse, it offers hope for a condition with limited treatment options.
30
What characterizes dementia?
Marked impairment in two or more cognitive domains, with memory impairment being common but not exclusive.
31
What are essential features of dementia according to ICD-11?
* Marked cognitive impairment
* Decline from previous functioning
* Evidence from individual or clinical observation
* Significant impairment in daily functioning
32
What differentiates delirium from dementia?
Delirium is characterized by global neurocognitive impairment and confusion with a transient onset, while dementia is progressive and gradual.
33
What is pseudodementia and how does it differ from true dementia?
Pseudodementia is cognitive impairment due to severe depression, often with greater awareness and distress about cognitive deficits.
34
What mnemonic can help remember potentially reversible causes of dementia?
DEMENTIA: Drugs, Emotions, Metabolic, Eyes and ears, Normal pressure hydrocephalus, Tumour, Infection, Anaemia.
35
What are some notable metabolic causes of dementia?
* Wilson's disease
* Hashimoto's encephalitis
* Hypo and hyperparathyroidism
* Cushing's disease
* Addison's disease
36
What investigations are suggested by NICE guidelines for dementia?
* Routine blood tests
* Urine microscopy and culture
* Chest X-ray
* Electrocardiogram (ECG)
* Neuroimaging
37
What structural changes are typically seen in Alzheimer's disease on MRI?
* Mesial temporal lobe atrophy
* Temporoparietal cortical atrophy
* Ventricular enlargement
38
What functional changes in Alzheimer's disease are demonstrated by SPECT and PET?
* SPECT: Temporoparietal hypoperfusion
* PET: Temporoparietal glucose hypometabolism
39
What early features are characteristic of vascular dementia?
* Similar to Alzheimer's but less memory affected
* Mood fluctuations
* Physical frailty
* Stepwise onset
40
What distinguishes early-onset dementia from late-onset dementia?
Early-onset occurs before age 65 and is associated with rarer forms of dementia.
41
What percentage of dementia cases are accounted for by Alzheimer's disease in older versus younger populations?
About two-thirds in older people, one-third in younger people.
42
What is the total population prevalence of dementia among those over 65 in the UK?
7.1%.
43
What is the median survival time from diagnosis to death for dementia?
Approximately 5-6 years.
44
What role does neuropsychological testing play in diagnosing dementia?
It helps delineate the nature and extent of cognitive impairments.
45
What are common features of cortical dementia?
* Language disturbances
* Difficulty recognizing familiar objects
* Problems with planning and executing tasks
* Memory impairments
46
What are common features of subcortical dementia?
* Slowness of thought processes
* Difficulty starting or stopping activities
* Changes in personality and mood
* Motor symptoms
47
What is the characteristic of Pick's disease?
Focal gyral atrophy with a knife-blade appearance.
48
What are the early symptoms of Huntington's disease?
Abnormal movements (chorea) and early onset (ages 35-44).
49
What are the key symptoms of progressive supranuclear palsy?
Loss of balance, falls, and problems with voluntary eye movements.
50
What is the prevalence of dementia among people over 65 years in the UK?
7.1%
## Footnote
This equals 1.3% of the entire UK population.
51
What is the most common cause of dementia in the UK?
Alzheimer's disease (62%)
## Footnote
Followed by vascular (17%) and Lewy body dementia (4%).
52
What are the proportions of dementia severity among people with late-onset dementia?
* 55% have mild dementia
* 30% have moderate dementia
* 15% have severe dementia
53
How does early onset dementia prevalence differ between genders?
Higher in men than in women for those aged 50-65
## Footnote
Late onset dementia is marginally more prevalent in women.
54
What is dementia?
An acquired syndrome of decline in memory and at least one other cognitive domain sufficient to interfere with social and occupational function.
55
What are the primary cognitive domains affected in dementia due to Parkinson's disease?
* Executive function
* Attentional function
* Visuospatial function
56
What cognitive deficits are less pronounced in dementia due to Parkinson's disease?
* Verbal memory
* Visual memory
57
What is the most common cause of stroke?
Cerebral infarction (84%)
## Footnote
Other causes include intracerebral hemorrhage (10%) and subarachnoid hemorrhage (6%).
58
What is the prevalence of post-stroke depression?
30-40%
## Footnote
Lesions in the left hemisphere basal ganglia play a crucial role.
59
What are the Maudsley key recommendations for treating post-stroke depression?
* SSRIs (fluoxetine and citalopram)
* Nortriptyline as an alternative
* Citalopram and escitalopram preferred with warfarin
60
What is the difference between dementia and depression based on symptom duration?
Dementia has symptoms of long duration, while depression has symptoms of short duration.
61
What are dopamine receptor agonists used for?
Treatment of Parkinson's disease
## Footnote
Examples include apomorphine and ropinirole.
62
What are the common psychiatric side effects associated with dopamine receptor agonists?
* Pathological gambling
* Binge eating
* Hypersexuality
63
What is the typical pattern of suicide rates in the elderly?
Traditionally highest in elderly men, now changing
## Footnote
Highest rates observed in men aged 35-44 years.
64
What are the main risk factors for completed suicide in the elderly?
* Male sex
* Use of violent method
* Existence of psychiatric disorder
* Significant medical condition
* Stressors/bereavement
* Living alone
65
What characterizes frontotemporal lobar degeneration (FTLD)?
Progressive dysfunction in executive functioning, behaviour, and language.
66
What are the subtypes of frontotemporal lobar dementia?
* Behavioural-variant (bvFTD)
* Language variant (Primary progressive aphasia)
* Semantic variant PPA
* Non-fluent agrammatic variant PPA
67
What are the symptoms of Huntington's disease?
* Depression
* Apathy
* Dementia
* Psychosis
* Anxiety
* Mania
* Sexual dysfunction
* Higher suicide rate
68
What is mild cognitive impairment (MCI)?
A transitional zone between normal cognitive function and clinically probable Alzheimer's disease.
69
What are the general criteria for mild cognitive impairment (MCI)?
* Not normal, not demented
* Self/informant report and impairment on cognitive tasks
* Evidence of decline over time
* Preserved basic activities of daily living
70
What is paraphrenia?
A late onset schizophrenic type presentation that is functional, not due to underlying organic illness.
71
What are common features of paraphrenia?
* More common in women
* Associated with hearing and visual impairment
* Less likely to be married
* Less likely to have children
72
What are the three classic motor symptoms of Parkinson's disease?
* Rigidity
* Bradykinesia
* Tremor
73
What is the principle abnormality in Parkinson's disease?
Degeneration of dopaminergic neurons in the pars compacta of the substantia nigra.
74
What is the age prevalence trend for Parkinson's disease?
Uncommon under 50, peaks between 85-89.
75
What is the main treatment focus for Parkinson's disease?
Symptomatic relief by restoring dopamine levels or acting on dopamine receptors.
76
What are the potential risks associated with levodopa treatment?
* Dyskinesia
* Impulse control disorder
77
What is the primary purpose of drugs used in Parkinson's Disease?
Symptomatic relief by restoring dopamine levels or acting on dopamine receptors
## Footnote
Dopamine is not the only neurotransmitter involved in Parkinson's Disease (PD), hence other drugs target specific symptoms.
78
What is Levodopa designed to do?
Replace dopamine in the depleted striatum
## Footnote
Levodopa may cause dyskinesia and has a lower risk of impulse control disorder compared to dopamine agonists.
79
Name one class of drugs that directly stimulates dopamine receptors.
Dopamine receptor agonists
## Footnote
Examples include bromocriptine, ropinirole, and apomorphine.
80
What is Amantadine used for in Parkinson's Disease?
Helps with tremor and rigidity
## Footnote
Its exact mechanism is unclear but may involve weak glutamate antagonism at NMDA receptors.
81
What do MAO-B inhibitors do?
Reduce the breakdown of dopamine
## Footnote
They are not as effective as Levodopa but can support its use.
82
What is the role of COMT inhibitors in Parkinson's Disease?
Reduce the breakdown of dopamine
## Footnote
Similar to MAO-B inhibitors, they are not as effective as Levodopa.
83
What are antimuscarinics used for in early stages of Parkinson's Disease?
Help with rigidity and tremor
## Footnote
They are mainly used in young patients and avoided in the elderly due to cognitive issues.
84
What percentage of Parkinson's Disease patients suffer from depression?
Up to 25%
## Footnote
Similar percentages also apply to anxiety and psychosis.
85
What is punding?
A constellation of complex, sterile, and stereotyped behaviors
## Footnote
Includes behaviors like excessive grooming and sorting objects.
86
What type of hallucinations are common in Parkinson's Disease?
Visual hallucinations
## Footnote
They can also be auditory or tactile, often involving people or animals.
87
True or False: Hallucinations in Parkinson's Disease are always caused by dopaminergic medication.
False
## Footnote
Hallucinations may occur independently of medication, as seen in the pre-dopa era.
88
What is the best tolerated antipsychotic for treating psychosis in Parkinson's Disease?
Low dose quetiapine
## Footnote
Clozapine is effective but limited by monitoring needs and physical risks.
89
What is the first-line treatment for depression in Parkinson's Disease according to Maudsley guidelines?
SSRI
## Footnote
Augmentation with dopamine agonists like pramipexole is also considered.
90
What is a key feature of Multiple System Atrophy (MSA)?
Parkinsonism and autonomic dysfunction
## Footnote
MSA has two subtypes: MSA-P and MSA-C.
91
What are the hallmark symptoms of Progressive Supranuclear Palsy (PSP)?
Vertical gaze palsy and cognitive changes
## Footnote
Patients often have a characteristic 'staring' expression and a tendency to fall backwards.
92
What is Corticobasal Degeneration (CBD) characterized by?
Asymmetric motor symptoms and cognitive changes
## Footnote
Unique symptoms include the 'alien limb phenomenon.'
93
What distinguishes Dementia with Lewy Bodies (DLB) from other Parkinson's plus syndromes?
Fluctuating cognitive impairment and recurrent visual hallucinations
## Footnote
Cognitive symptoms often precede or develop concurrently with motor symptoms.
94
What is Pseudobulbar Affect?
Pathological crying or laughing not congruent with mood
## Footnote
It can be provoked by minor stimuli.
95
What neurological problems can lead to Pseudobulbar Affect?
Strokes and Multiple Sclerosis
## Footnote
Strokes have an 11% incidence of this condition one year post-event.
96
What is a common treatment for pathological crying after a stroke?
Citalopram
## Footnote
It has shown superior efficacy compared to tricyclic antidepressants.
97
True or False: SSRIs can increase the risk of bleeding.
True
## Footnote
This is due to serotonin deficiency in platelets and increased gastric acid secretion.
98
Who is at higher risk of bleeding when taking SSRIs?
Elderly, those with a history of bleeding, and those using anticoagulants
## Footnote
Other factors include liver disease and renal disease.
99
What is the Maudsley recommendation for SSRIs in patients on NSAIDs?
Avoid SSRIs if possible
## Footnote
If unavoidable, prescribe gastroprotective proton pump inhibitors.
100
Which antidepressant is preferred for treatment post Myocardial Infarction (MI)?
SSRIs
## Footnote
They are preferred despite the risk of increased bleeding.
101
What percentage of people develop depression post MI?
Approximately 20%
## Footnote
Goodman, 2008
102
What is the preferred antidepressant group post MI?
SSRIs
## Footnote
SSRIs can increase bleeding risk, especially in those using anticoagulation.
103
What is an alternative option to SSRIs for treating depression post MI?
Mirtazapine
## Footnote
Mirtazapine is also associated with bleeding (Na, 2018).
104
What did the SADHART study investigate?
The safety of sertraline for treating depression post-myocardial infarction
## Footnote
Glassman, 2002
105
What percentage of completed suicides occur in the elderly?
Approximately 20%
## Footnote
Cattell, 1995
106
What mental health condition is commonly found in elderly individuals who commit suicide?
Depressive disorder
## Footnote
Over half of those who commit suicide after 65 years are suffering from depression.
107
What personality traits are associated with suicide in older people?
Anankastic (obsessional) and anxious personality traits
## Footnote
Harwood, 2001
108
What does testamentary capacity refer to?
An individual’s legal and mental ability to make a valid will
109
What case established the requirements for testamentary capacity?
Banks v Goodfellow
110
What are the four requirements for testamentary capacity?
* Understand the nature and effect of making a will
* Know the extent of their estate
* Understand the claims of potential beneficiaries
* Not be influenced by mental illness affecting intentions
111
What can bereavement legally qualify as regarding testamentary capacity?
A mental condition that may undermine capacity
112
What is the standard of proof for testamentary capacity?
On the balance of probability
113
What is presumed about a rational, properly executed will?
It is presumed valid unless there is substantial doubt about the testator’s capacity
114
What is transient global amnesia characterized by?
Abrupt onset of severe amnesia usually accompanied by repetitive questioning
115
What are the diagnostic criteria for transient global amnesia?
* Attacks must be witnessed
* Clear cut anterograde amnesia during the attack
* Clouding of consciousness and loss of personal identity must be absent
* No accompanying focal neurological symptoms
* Epileptic features must be absent
* Attacks must resolve within 24 hours
* Recent head injury or known active epilepsy are excluded
116
What role does thromboembolic cerebrovascular disease play in transient global amnesia?
It plays no part in the causation
117
What is often a precipitant for transient global amnesia?
Valsalva maneuver
## Footnote
Other precipitants include exertion, cold, pain, emotional stress, and sexual intercourse.
118
True or False: EEG recording is characteristically abnormal after an attack of transient global amnesia.
False
## Footnote
EEG is characteristically normal after an attack.
