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Y4 OPIC > Older Persons Mental Health > Flashcards

Older Persons Mental Health Flashcards

1
Q

What cognitive assessments are used for dementia?

A
  • Folstein Mini-Mental State Examination (MMSE)
  • The Abbreviated Mental Test (AMT)
  • The Addenbrooke’s Cognitive Examination (ACE)
  • General Practitioner Assessment of Cognition (GPCOG)
  • The Montreal Cognitive Assessment (MOCA)
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2
Q

What cognitive assessments are used for delirium?

A
  • Abbreviated Mental Test (AMT)
  • Confusion Assessment Method (CAM)
  • Mini-Mental State Examination (MMSE)
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3
Q

Briefly differentiate between delirium and dementia

Note: sleep wake cycle, attention, arousal, autonomic features, duration, delusions, course, consciousness level, hallucinations, onset and psychomotor activity

A
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4
Q

Briefly describe the epidemiology of delirium

A

Delirium occurs in about 15– 20% of all general admissions to hospital.

Delirium is the most common complication of hospitalisation in the elderly population.

Up to two-thirds of delirium cases occur in inpatients with pre-existing dementia.

15% of >65 s are delirious on admission to hospital.

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5
Q

Briefly describe the epidemiology of dementia

A

There are currently 800 000 people with dementia in the UK and it is estimated that there will be over one million by 2021.

Dementia increases with age (rare if <55 years; 5– 10% if >65 years ; and 20% if >80 years ).

Overall prevalence is similar in ♂ and ♀, but AD is more common in ♀, whereas vascular and mixed dementias are more common in ♂.

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6
Q

What are the clinical features of delirium?

A
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7
Q

What are the clinical features of dementia?

A
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8
Q

Briefly describe the causes of delirium

A
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9
Q

Briefly describe the causes of dementia

A
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10
Q

What physical changes occur to the brain as age increases?

A

The following changes occur in brain as a part of normal ageing:

  • The weight of the brain decreased by 5-20% between 70 and 90 years with a compensatory increase in ventricular size
  • There is neuronal loss, especially in the hippocampus, cortex, substantia nigra and cerebellum
  • Senile plaques are found in the neocortex, amygdala and hippocampus
  • Tau proteins form neurofibrillary tangles, found normally only in the hippocampus
  • Lewy bodies are seen in the substantia nigra
  • Ischaemic lesions are seen in 50% of normal people over the age of 65
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11
Q

What psychological changes occur as age increases?

A

From mid life there is a decile in intellectual functions, as measursed with standard intelligence tests, together with deterioration of short-term memory and slowness. IQ peaks ar 25 years, remains stable until 60-70 years and then deciles. Problem solving reduces after about age 60.

There may be changes in personality and attitudes, such as increasing cautiousness, rigidity and ‘disengagement’ from the outside world.

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12
Q

What social changes occur as age increases?

A

Later life presents a serious of major changes. Many indiviudals retire, lose partners, lose their physical health and are forced to live on much lower incomes and in poorer-quality housing than younger people.

These are difficult transitions which may predispose to mental illness. The majority of older people remain living at home: 50% with a partner and 10% with other family members. Those who live alone may become isolated and lonely.

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13
Q

Briefly describe the epidemiology of psychiatric conditions as age increases

A

The greatest budern of diease is in 2 areas:

  • Mood and anxiety disorders
  • Cognitive impairment
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14
Q

What types of mental disorders are seen in older patients?

A

Many of the same disorders affect older people as affect younger people. They can be subdivided into 3 types:

  1. Pre-existing problems that continue to older age
  2. New diagnoses after the age of 65
  3. Mental health disorders associated with ageing

Common diagnoses include:

  • Dementia
  • Delirium
  • Mood disorders
  • Anxiety disorders
  • Psychoses, schizophrenia and delusional disorder
  • Suicide and deliberate self-harm (DSH)
  • Alcohol and substance misuse
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15
Q

The assessment of older people presenting with a psychiatric problem is fundamentally the same as in the younger population. However, what factors need extra consideration?

A
  1. Is this an episode of a recurrent problem or a new diagnosis?
  2. Are the symptoms being caused by mentall illness or could it be organic pathology (e.g. brain tumour or dementia)?
  3. What physical illnesses does this patient have and do these complicate the situation?
  4. What is the patient’s living situation and what is their level of function in activities of daily living?
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16
Q

Who is involved in the MDT when assessing an older person’s mental health?

A

The assessment should be taken by a MDT team including psychiatrist, psychologist, occupational therapist, physiotherapist and social worker.

17
Q

What parameters need to be included when assessing an older person’s mental health?

A

A full assessment will include:

  • Full history from the patient, family and involved professionals
  • Full physical and neurological examination
  • Full cognitive assessment (including a MMSE)
  • Functional assessment (activities of daily living and mobilisation)
  • Social assessment (housing, finances and activities)
  • Assessment of carers’ needs
18
Q

What specific information needs to be obtained during the history/ assessment of an older person?

A
  • Timing of onset of symptoms and their subsequent course
  • Previous similar episodes
  • A description of behaviour over a typical 24 hours
  • Previous medical and psychiatric history (including intellectual ability and personality characteristics
  • Accurate drug history
  • Family history of psychiatric problems
  • Living conditions
  • Ability for self-care, shopping, cooking and laundry
  • Ability to manage finances and deal with hazards e.g. fire
  • Any behaviour that may cause difficulties for carers of neighbours
  • The ability of family and friends to help
  • Other services already involved in the patient’s care
19
Q

Briefly recap the features of a mental state examination (MSE

Note: NOT mini mental state examination (MMSE)

A
  1. Appearance and behaviour
  2. Speech
  3. Mood
  4. Thoughts
  5. Perception
  6. Cognition
  7. Insight
20
Q

Briefly describe the appearance and behaviour (MSE) of an older patient presenting with mental health problems

A

Observation of the patient’s clothin, personla cleanliness and home environment provides valuable information. Looks for signs that suggest these are chronic problems rather than acute illness.

Agitation and psychomotor retardation may be obvious.

Wandering, incontinence and disorientation may point to dementia.

21
Q

Briefly describe the speech (MSE) of an older patient presenting with mental health problems

A

Dysphagia is frequently seen in moderate to advanced dementia, or after a stroke.

In delirium, dementia or alcohol excess, speech may be inappropriate.

Lack of speech may suggest depression and excessive quantities of rapid speech may suggest mania.

22
Q

Briefly describe the mood (MSE) of an older patient presenting with mental health problems

A

Older people may not admit to low mood, sadness or depression. Anhedonia, fatigue, weight loss, anorexia and insomnia are common.

Suicidal ideation and passitve death with are more common in older than in younger adults.

Florid mania is rare, but present as in younger patients.

23
Q

Briefly describe the thoughts (MSE) of an older patient presenting with mental health problems

A

There are no specific differences in older people.

Anxiety is very common.

Delusions are seen in depression, delusional disorder, delirium and dementia.

24
Q

Briefly describe the perception (MSE) of an older patient presenting with mental health problems

A

Hallucinations are common in dementia and delirium, but also in pre-existing or late-onset psychoses.

Visual hallucinations are particularly associated with delirium and alcohol withdrawal.

25
Q

Briefly describe the cognition (MSE) of an older patient presenting with mental health problems

A

The MMSE is the best tool to assess cognition.

A 10-point abbreviated mini mental test score may also be helpful.

26
Q

Briefly describe the insight (MSE) of an older patient presenting with mental health problems

A

This is frequently poor. Good insight into low mood suggests depression rather than dementia.

27
Q

What tests can be used to quantify the level of cognitive impairment?

A

Abbreviated Mental Test Score (AMTS): out of 10 points, score of 6 or less taken as delirium.

MMSE: out of 30 points, with more than or equal to 25 taken as normal, mild dementia 21-24, moderate 10-20 and severe less than 10 points. It tests the domains of orientation, attention, calculation, memory and language.

The AMTS is often used sequentially to monitor improvement or decile in funcitoning. The MMSE is primarily used for dementia but may be helpful in delirium.

28
Q

What psychiatric services are available for the older patient?

A
  • Psychiatric inpatient units
  • Acute medical wards
  • Consultation and liaison services
  • Day hospitals
  • Community outpatient services
  • Specialist residential care
  • Respite care
  • Primary care
29
Q

In most situations, the treatment of psychiatric disorders in older adults resembles that of the same conditions in younger adults, although there are some differences. What differences require emphasis?

A
  • It is more often necessary to treat concurrent physical disorders
  • Maintaining function and independence is parmount
  • Special caution is needed in drug dosages
  • Social measures must be considered
  • Families need to be involved and supported
  • Capacity and other ethical issues are important
30
Q

What ethical and legal issues may arise in the elderly?

A
  • Confidentiality in relation to information from carers
  • Confidentiality of information about financial circumstances
  • Consent to treatment:
    • Capacoty to consent to physical and psychological treatment
    • Advance directives
    • Decisions ‘not to treat’
  • Management of financial affairs:
    • Nominating another to take responsibility (power of attorney)
    • Procesures to enable others to take responsibility
  • Entitlement to drive a car
31
Q

What social considerations need to be made when treating older adults?

A
  • Psychosocial treatments
  • Encourage self-care
  • Social contacts
  • Legal and financial advice
  • Financial
  • Driving
  • Determing mental capacity
  • Social services
  • Domiciliary
  • Day care
  • Residential and nursing care
  • Voluntary services
32
Q

Why should antipsychotics be avoided in the elderly?

A

Behavioural and/ or psychiatric problems such as psychosis, agitation and aggression are common in patients with Alzheimer’s disease. They can make managing the patient challenging and are psychologically difficult for both the patient and carer.

First-generation antipsychotics have been used for several decades, and are probably at least partly effective but run a high risk of sedation and extrapyramidal side effects. The use of atypical antipsychotics has increased, but their use has been controversial.

One problem has consistently arisen in this area. Atypical antipsychotics seem to be associated with a greater risk of stroke and all-cause mortality when used in AD patients.

33
Q

What are the extrapyramidal effects of antipsychotic drugs?

A
34
Q

What are the clinical features of acute dystonia?

A
  • Torticollis
  • Tongue protrusion
  • Grimacing
  • Spasm of ocural muscles
  • Opisthotonus
35
Q

What are the clinical features of parkinsonism?

A
  • Bradykinesia
  • Expressionless face
  • Lack of associated movements when walking
  • Stooped posture
  • Rigidity of muscles
  • Coarse pill rolling tremor
36
Q

What are the clinical features of tardive dyskinesia?

A
  • Chewing and sucking movements
  • Grimacing
  • Choreoathetoid movements
  • Akathisia
37
Q

Briefly describe the management of dementia

A

Y4 OPIC (14 decks)

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