Older Persons Mental Health Flashcards
When taking a history for a pt with cognitive impairment,. what questions do you need to ask?
Presenting compliant
- Duration
- Onset/course
- Example questions: forgetfulness, forget names, getting lost etc…
- Ensure to ask about behavioural & psychiatric symptoms of dementia & any triggers (includes hallucinations, delusions)
- Impact on life
- ADLs
- Washing, dressing, eating/drinking/cooking, shopping, housework, financial/bills
- Continence
- Safety
PMH
- Risk factors
- PMH
- Medications
- Allergies
FH
- Dementia (and age)
Social
- Who live with
- Where live
- Socialise much
- Any support at home
ICE
- Do they have insight
Notes from memory clinic regarding histories
What history should you always take when assessing a pt with cognitive impairment?
Collateral history
(ask similar questions as to what you would ask person but in different way. Ask about pre-morbid self, memory, personality changes, behaviour changes, ADLs, concerns, rest of hx you can’t get from pt)
State some tools commonly used to assess cognitive ability
- AMTS (abbreviated mental test score): useful as very quick cognition screen
- MMSE (mini mental state examination): copyright issues so not used as much now
- ACE-III (Addenbrooke’s cognitive examination III): more in depth, 100 points, need to see pt face to face as some writing involved/need to identify pictures
- CAM (confusion assessment method): used to support delirium diagnosis
- MOCA (Montreal Cognitive Assessment): used more than MMSE now due to copyright issues with MMSE
- MIS-T CHECK!!!
Remind yourself of AMT-10
Questions
- Age
- Time to nearest hour
- Year
- Either name of where they are or their home address
- Recognise two people (e.g. chef, post-man, doctor)
- DOB
- Date WW1 began (can ask WW2)
- Name of monarch or prime minister
- Count backwards from 20 to 1
- Repeat address (should be given after asking time)
Results
0-3 = severe impairment
4-6= moderate impairment
≥ 7 = normal
Remind yourself briefly of what is involved in MMSE
Remind yourself of 4 parts of CAM (Confusion Assessment Method)
Remind yourself briefly of what is involved in ACE-III
Cognitive test that assesses five cognitive domains: attention, memory, verbal fluency, language and visuospatial abilities. Need to see images & draw hence need to do in person
Remind yourself briefly what is involved in GP-COG
- Designed as dementia screening tool for GPs
- Two parts: one to be completed by pt and one to be completed by informant if results from pt questionnaire inconnclusive
Remind yourself briefly of what is involved in MOCA (Montreal Cognitive Assessment)
Summary from memory clinic:
- GP-COG and MOCA often used in GP settings as quick tool
- ACE-III or mini-ACE used in memory clinics
- FAB (frontal assessment battery) used alongside ACE-III in memory clinic if you suspect FTD
What is dementia?
Discuss prevalence/epidemiology
- Dementia is a clinical syndrome of generalised, progressive, irreversible decline of memory, intellect and personality- without impairment of consciousness- leading to functional impairment
- Prevalence:
- WHO says 50 million people world wide
- NICE CKS: 885,000 in UK in 2019
- GOING TO INCREASE
Dementia is irreversible however you may hear people talk about reversible causes of dementia; state some examples of reversible causes of dementia
*HINT: mnemonic for reversible causes is DEMENTIA
MANAGEMENT= treat underlying cause
Dementias can be classified as cortical, subcortical or mixed based on where dysfunction is most predominant. Compare cortical and subcortical dementias based on the following:
- Memory loss
- Mood
- Speech & aphasia
- Personality
- Coordination
- Praxis
- Motor speed
Sate some examples for each
- Cortical: Alzheimer’s dementia, FTD
- Subcortical: DLB, Parkinson’s disease with dementia
- Mixed: vascular
State some different types of dementia
**These are ones you need to know more about
- Alzheimer’s dementia
- Vascular dementia
- Dementia with lewy body
- Frontotemporal dementia
- Parkinson’s disease with dementia
- Mixed dementia
- Reversible dementia
- AIDs-dementia complex
- Huntington
- Other neurodegenerative dementias
- CJD,
- Syphilis)
- AIDs dementia complex
- Huntington’s
- Wernicke-Korsakoff syndrome
State the 4 most common types of dementia
- Alzheimer’s disease (50–75%), more common in women, often co-exists with other forms of dementia such as vascular dementia.
- Vascular dementia (up to 20%), more common in men
- Dementia with Lewy bodies (10–15%).
- Frontotemporal dementia (2%).
Discuss the ICD-10 criteria for diagnosing dementia
What is early onset dementia?
Dementia before 65yrs
What investigations would you request for someone with suspected dementia and why?
(Not including cognitive assessment tools)
-
Investigations to exclude potential reversible causes (may often be done in primary care):
- Urine dipstick
- FBC: ?infection or anaemia
- U&E: ?impaired renal func
- Calcium: if not on U&Es
- LFTs: ?impaired liver function
- Coagulation/INR: ?bleeding risk
- Glucose: ?hypoglycaemia or hyperglycaemia
- Calcium: ?abnormalities
- ESR/CRP:?infection
- TFTs: ?hypothyroidism
- Vit B12: ?deficiency
- Folate: ?deficiency
- May also consider others such as urinalysis, blood cultures, CXR, thiamine, drug levels (it pt on digoxin, lithium, quinidine), thiamine
- Referral to old age psychiatrist (often refer to memory clinics)
- In secondary care, neuroimaging (e.g. CT head)
Discuss whether dipsticks are reliable for diagnosing UTIs in the elderly
- Urine dipstick not reliable for pts >65yrs or those with catheter
- A positive urine dipstick without clinical signs is NOT satisfactory to diagnose urinary tract infection as a cause of delirium
- Look for other evidence supporting the diagnosis (WCC↑/supra-pubic tenderness/dysuria/offensive urine/positive urine culture).
What do we mean by BPSD?
Behavioural and psychiatric symptoms of dementia, including:
- Agitation
- Restlessness, pacing and wandering
- Anxiety
- Elation
- Irritability
- Depression
- Apathy
- Disinhibition
- Delusions
- Hallucinations
- Sleep or appetite change
For Alzheimer’s dementia, discuss:
- Pathogenesis
- Risk factors
- *
Pathophysiology:
- Macroscopic: widespread cerebral atrophy
- Microscopic:
- Type A-beta amyloid plaques due to wrong enzymes degrading amyloid protein forming insoluble beta amyloid which aggregates outside neurones to form plaques
- Intraneuronal neurofibrillary tangles due to abnormal aggregation of TAU protein
- Biochemical: deficiency of acetylcholine
Risk factors:
- Advancing age
- FH
- Genetics (see separate FC)
- Down’s syndrome (associated early onset)
- Low IQ/learning disability
- Cerebrovascular disease (strong risk factor for vascular dementia which can co-exist with AD)
- Vascular risk factors (see above)
Discuss presentation of Alzheimer’s disease (focusing on late onset)
Gradual onset of:
-
Memory loss
- Initially inability to recall new info
- Long term memory declines as disease progresses
- Disorientation to time and place
- Impairment of executive functions
- Visuospatial impairment (i.e. get lost)
- Language disturbances/dysphasia (i.e. can’t find words, decreased vocabulary, repeating same word or gesture, global aphasia)
- Apraxia (inability to carry out previously learned movements e.g. buttoning a shirt)
- Agnosia (impaired recognition of sensory stimuli not attributed to sensory loss e.g. can’t recognise familiar faces, can’t recognise sound)
- Non-cognitive/behavioural:
- Abnormal perceptions (e.g. hallucinations, delusions)
- Emotion (e.g. depression, apathy)
- Behaviour (e.g. wandering, aggression, restlessness)
*SEE image for early onset. Idea that early onset is more rapid onset and intellectual impairment predominates
Discuss disease progression of Alzheimer’s disease
What is the triad seen in normal pressure hydrocephalus?
- Dementia with prominent frontal lobe dysfunction
- Urinary incontinence
- Gait disturbance (wide gait)
Delirium can be hypoactive, hyperactive or mixed; explain the difference
State some common causes of delirium- highlighting most common
*HINT: CHIMPS PHONED
Most cases of delirium are multifactorial. MOST COMMON CAUSE IS UTI. Common causes include:
- Constipation
- Hypoxia
- Infection
- Metabolic disturbance
- Pain
- Sleeplessness
- Prescriptions
- Hypothermia/pyrexia
- Organ dysfunction (hepatic or renal impairment)
- Nutrition
- Environmental changes
- Drugs (over the counter, illicit, alcohol and smoking)
*NOTE: A change in environment coupled with sensory impairment (common in the elderly) increases the risk of developing delirium.
Describe typical presentation of delirium
Acute onset of symptoms, fluctuating course often worse at night
Presentation will vary dependent on if hypoactive, hyperactive or mixed delirium
Discuss the management of delirium (hint, think about 4 key categories of management)
- *Also having photos/other familiar objects around bedside*
- *Other sources say low dose lorazepam not olanzapine*
Antipsychotics & benzodiazepines are NOT first line management. Treating underlying cause, reassurance, re-orientation & appropriate environment are main means for treating delirium. Should only use pharmacological agents in last resort in cases of violent or severely distressed behaviour when other management strategies have failed
Compare dementia & delirium in terms of:
- Sleep-wake cycle
- Attention
- Arousal
- Autonomic features
- Duration
- Delusions
- Course
- Conscious level
- Hallucinations
- Onset
- Psychomotor activity
How is mild cognitive impairment different to dementia?
Term used to describe stage between normal ageing and dementia; does not interfere significantly with daily life
