OPIC - Older Person's Mental Health

Question 1

Capacity

Who Lacks Capacity?
2-Stage Capacity Test
Making Best Interest Decisions
Assessing Capacity

Answer 1

1. ) Who Lacks Capacity? - examples include:
   - schizophrenia, bipolar, severe learning disabilities
   - delirium, dementia, brain damage/injury, LOC
   - drowsiness, intoxication with drugs or alcohol
2. ) 2-Stage Capacity Test - Mental Capacity Act 2005
   - 1: cognitive impairment due to illness or drugs/alcohol
   - 2: their capacity is time-specific and decision specific, should try to give them time for their capacity to return
3. ) Assessing Capacity
   - understand information relevant to the decision
   - retain that information
   - weigh that information into their decision-making
   - communicate their decision
4. ) Making Best Interest Decisions - if lacks capacity
   - care of the patient is the first concern
   - use advocates the patient may have identified
   - what the patient would have wanted if had capacity
   - treat patients as individuals and with dignity

Question 2

Legalities in Decision Making

Advance Statements
Advance Decision to Refuse Treatment
Lasting Power of Attorney (LPS)
Deputies appointed by the Court of Protection
Deprivation of Liberty Safeguards (DoLS)

Answer 2

1. ) Advance Statements - not legally binding
   - written statement that sets down your preferences, wishes, beliefs and values regarding your future care
2. ) Advance Decision (to Refuse Treatment)
   - decision to refuse a specific type of treatment at some time in the future. It is legally binding
3. ) Lasting Power of Attorney (LPS) - a legal document that lets you appoint one or more people to make decisions on your behalf when you lack capacity
   - types: health+welfare, property+financial affairs, only health+welfare allows them to make medical decisions
4. ) Deputies appointed by the Court of Protection
   - court of protection assigns a deputy to essentially act as your lasting power of attorney
5. ) Deprivation of Liberty Safeguards (DoLS)
   - A means to protect the rights of patients who lack capacity who are detained in a hospital or care home
   - when it’s necessary to deprive a patient (who lacks capacity) of their liberty to keep them safe from harm
   - procedure prescribed in law, can only be used in a care home or hospital and must ask the local authority
   - can be used for up to 1 year

Question 3

Sectioning Under the Mental Health Act

Section 2
Section 3
Section 5
Community Treatment Order (Section 17a)
Section 135
Section 136

Answer 3

1. ) Section 2 - up to 28 days, not renewable
   - requires an approved MH professional (AMHP)
   - treatment can be given against a patient’s wishes
   - section 4 is a 72hr assessment order which is often changed to a section 2 upon arrival at a hospital
2. ) Section 3 - up to 6 months, can be renewed
   - requires an AMHP along with 2 doctors who must have seen the patient within the past 24 hrs
   - treatment can be given against a patient’s wishes
3. ) Section 5 - for voluntary patients in hospital
   - 5(4): doctor can legally detain a patient for 72 hours
   - 5(2): nurse can legally detain a patient for 6 hours
4. ) Community Treatment Order (Section 17a)
   - used to recall a patient to the hospital for treatment if they do not comply with conditions of the order in the community, such as complying with medication

5.) Section 135 - allows the police to break into a property to remove a person to a Place of Safety

6. ) Section 136 - allows the police to take a person from a public place (w/ suspected mental disorder) to a Place of Safety for up to 24 hours
   - a Mental Health Act assessment should be arranged

Question 4

Delirium

Pathophysiology
Precipitating Factors
Clinical Features
Complications

Answer 4

1. ) Pathophysiology - acute onset (1-2 days) of confusional state w/ altered level of consciousness
   - can be hyperactive, hypoactive or mixed (fluctuating)
   - hyperactive is more common but easier to spot
   - hypoactive has a worse prognosis
   - risk factors: >65s, dementia, significant injury e.g. hip fracture, frailty, multimorbidities, polypharmacy
2. ) Precipitating Factors - can be multi-factorial
   - infection: particularly a UTI or chest infection
   - metabolic: ↑/↓ Na+, ↑Ca2+, ↑/↓ BG, dehydration
   - severe pain, alcohol withdrawal, environment change
   - significant cardio, resp, neuro or endocrine condition
   - medications: opioids, anti-cholinergic, antidepressants, antipsychotics, anticonvulsants,
   - others: illicit drugs, hypoxia, ↓sleep, hypothermia, malnutrition, organ dysfunction
3. ) Clinical Features
   - duration: days (hours to weeks), can be longer depending on the previous mental state
   - fluctuating sx: worse at night, periods of normality
   - hyperactive: sleep-wake disturbance, agitation, wandering, aggression, hallucinations,
   - hypoactive: inattention, ↓arousal, lethargy, withdrawal
   - others: short-term memory disturbance
4. ) Complications
   - delirium can continue for a period of time after the cause has been treated
   - increased mortality, prolonged admission, increased risk of developing dementia
   - can take up to 3 months to return to baseline whilst some never get back to their baseline

Question 5

Delirium vs Dementia

Onset and Progression
Hallucinations
Speech
Consciousness and GCS

Answer 5

1. ) Onset and Progression
   - delirium: rapid onset with a fluctuating course
   - dementia: slow onset and steady decline
2. ) Abnormal Perceptions - delusions, hallucinations
   - can be present in delirium, whilst rare in dementia
3. ) Speech - can both be slow but delirium can be fast
4. ) Consciousness and GCS - reduced in delirium

Question 6

Management of Delirium

Investigations
Cognitive Assessments
Environmental Management
Pharmacological Management

Answer 6

1. ) Investigations
   - basic obs/EWS, GCS/AVPU,
   - confusion screen: FBC, CRP, blood cultures, U+Es, LFTs, TFTs, clotting, bone profile, haematinics, glucose
   - urine dip: must also have clinical sx to diagnose UTI
   - imaging: CXR, CT Head
2. ) Cognitive Assessments
   - Abbreviated Mental Test (AMT-10): score of <8 is suggestive of possible confusion, do another test:
   - 4AT: a specific delirium assessment tool
   - Confusion Assessment Method (CAM) is much longer and more specific
   - MMSE can also be used to exclude delirium
3. ) Environmental Management - first-line
   - move into a separate room, clocks to orientate them
   - familiar objects and familiar people around them
   - ↓noise, adequate lighting, ambient temperature

4.) Pharmacological Management - last-line, persistent wandering and delirium aren’t indications for sedation
- sedatives can actually worsen delirium
- (PO/IM/IV) haloperidol (0.5mg) or olanzapine first-line
- anti-psychotics are contraindicated in Parkinson’s as they worsen sx so haloperidol shouldn’t be used
- lorazepam or atypical antipsychotics (e.g. olanzapine)
are used instead

Question 7

Dementia

General Information
Risk Factors
Cognitive Features
BPSD - Behavioural and Psychological Sx of Dementia
Differential Diagnosis

Answer 7

1. ) General Information - progressive, irreversible syndrome with a range of cognitive and behavioural sx
   - 850,000 in the UK, 1/14 of over 65s with dementia
   - 50-75% Alzheimer’s, up to 20% vascular
   - 10-15% Lewy-body, 2% frontotemporal
2. ) Risk Factors
   - ↑age, mild cognitive impairment, LD (e.g. Down’s)
   - genetic, cardio/cerebrovascular disease, Parkinson’s
   - smoking, alcohol, HTN, diabetes, obesity, depression
3. ) Cognitive Features
   - memory loss: learning new info, recent events, people’s names, vague w/ dates, miss appointments
   - dysphasia and dyspraxia, disorientation (time, place)
   - ↓executive function: planning, problem-solving
4. ) BPSD - can fluctuate, can last > 6 months
   - difficulties w/ ADLs: eating, hygiene, dressing etc.
   - motor disturbance: wandering, restlessness, pacing
   - agitation and emotional lability: easily upset, mood swings, argumentative, challenging behaviour
   - sleep cycle disturbance, social or sexual disinhibition
   - depression and anxiety, withdrawal or apathy
   - psychosis: delusion and/or hallucinations

• risks: driving, wandering, leaving stove on etc…

5. ) Differential Diagnosis - ‘reversible dementia’
   - mild cognitive impairment (MCI): not severe enough to diagnose dementia, ↓impact on ADLs, ↓progression
   - depression, delirium, vision and hearing deficits
   - thiamine/B12/folate deficiency, hypothyroidism
   - medication: polypharmacy, sedatives, anticholinergic adverse effects, antiepileptics, corticosteroids, NSAIDs
   - normal pressure hydrocephalus (dementia + urinary incontinence + gait abnormality)
   - brain tumour, subdural, HIV

Question 8

Assessment and Management of Dementia

Examinations
Cognitive Assessment Tools
Investigations
Non-Pharmacological Management

Answer 8

1. ) Examinations
   - neurological: sensory, motor, visual, auditory sx, coordination and gait abnormalities
   - cardiovascular: HTN, arrhythmias, PVD
2. ) Cognitive Assessment Tools - all only suggestive
   - GPCOG: patient score out of 9, 8+ = normal, 0-4 = cognitive impairment, 5-8 = inconclusive
   - MMSE: better to exclude dementia, out of 30, 24+ is normal, 19-23 = mild, 10-18 moderate, 0-8 = severe
   - others: 10 point cognitive screener (10-CS), test your memory (TYM)
3. ) Investigations - to exclude reversible causes
   - bloods (to exclude reversible causes): FBC, CRP, U+Es, LFTs, TFTs, HbA1c, Calcium, B12/folate
   - urine dip +/- MC+S, CXR, ECG, HIV/syphilis testing
   - CT/MRI: first-line, used to clarify the subtype apart from frontotemporal which can be a clinical diagnosis
4. ) Non-Pharmacological Management
   - risk assessment: driving (patient/doctor must inform DVLA), cooking, neglect, wandering, alcohol, smoking

• MDT approach: GP, psychiatrist, occupational therapist, support worker, carer, Age UK
• tailored activities to the patient to promote wellbeing
• group cognitive stimulation therapy for mild-mod
• group reminiscence and cognitive rehabilitation
• must inform DVLA: either the patient or doctor

Question 9

Alzheimer’s Dementia

Pathophysiology
Genetics
Clinical Features
Pharmacological Management

Answer 9

1. ) Pathophysiology - abnormal proteins kill neurones
   - ß-amyloid plaques: accumulate and clump together between neurones due to abnormal breakdown
   - neurofibrillary tau tangles: tau protein is abnormal and microtubule structures collapse inside the neurone
   - macroscopic changes (CT/MRI): global atrophy, sulcus widening, enlarged 3rd/4th interventricular spaces
2. ) Genetics - defects in these proteins:
   - early onset: ß-amyloid precursor, presenilin 1/2
   - late-onset: apolipoprotein E gene
   - most cases are sporadic, linked to Down syndrome
3. ) Clinical Features
   - progression: insidious onset with slow progression
   - usually presents with cognitive decline: memory loss, difficulty w/ executive function or nominal dysphasia
   - 4As: amnesia, aphasia, apraxia, and agnosia
4. ) Pharmacological Management - AChE inhibitors (donepezil, rivastigmine, galantamine) or memantine
   - monotherapy: AChEi or memantine (if severe)
   - memantine if AChEi are contraindicated/intolerant or are already on an AChEi for other reasons
   - avoid antidepressants, antipsychotics only used if psychosis is causing them severe distress

Question 10

Vascular Dementia

Pathophysiology
Diagnostic Features
Pharmacological Management

Answer 10

1. ) Pathophysiology - cerebrovascular disease causing ischaemia or haemorrhage
   - sub-types: stroke-related VD (infarct), subcortical VD (small vessel disease), mixed VD (VD+Alzheimer’s)
   - risk factors: h/o of stroke/TIA, AF, HTN, DM, obesity, hyperlipidemia, smoking, coronary heart disease
   - initial management involves ↓ these risk factors

2.) Diagnostic Features - step-wise deterioration of cognitive function with focal neurological symptoms
- cognitive decline interfering w/ ADLs
- abrupt deterioration in cognitive functions or
fluctuating, stepwise progression of cognitive deficits
- cerebrovascular disease: on MRI or focal neuro sx: seizures, problems w/ vision, speech, weakness, gait
- onset of dementia w/in 3 months of a stroke

3.) Pharmacological Management - only if they have VD along with Alzheimer’s, Parkinson’s or Lewy-body

Question 11

Lewy Body Dementia

Pathophysiology (+4 locations)
Clinical Features
Investigations
Pharmacological Management

Answer 11

1. ) Pathophysiology - aggregation of alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the brain:
   - substantia nigra, paralimbic and neocortical areas
2. ) Clinical Features
   - gradually progressive cognitive impairment
   - fluctuating cognition, attention and alertness
   - often presents w/ early impairment in cognitive function, memory loss not as apparent in early stages
   - parkinsonian features (e.g. bradykinesia, rest tremor, or rigidity) usually develops after cognitive impairment
   - recurrent visual hallucinations as well as delusions
   - REM sleep behaviour disorder
3. ) Investigations - clinical diagnosis but can also use:
   - SPECT (single-photon emission CT)/DaTscan: scans uptake of dopamine, (90% sensitivity, 100% specificity)
4. ) Pharmacological Management
   - donepezil and/or rivastigmine (both if severe)
   - galantamine if others not tolerated
   - memantine if AChE inhibitors contraindicated
   - avoid anti-psychotics as they can cause irreversible parkinsonism

Question 12

Frontotemporal Dementia (Pick’s Disease)

Pathophysiology
Clinical Features
Pharmacological Management

Answer 12

1. ) Pathophysiology - atrophy of frontal/temporal lobe
   - focal gyral atrophy with a knife-blade appearance
   - microscopic changes: pick bodies (accumulations of TAU protein that stain with silver), gliosis, neurofibrillary tangles, senile plaques
   - insidious and early onset (<65)
2. ) Clinical Features
   - personality change and impaired social conduct
   - disinhibition, dysphasia (expressive or receptive)
   - ↑appetite, hyperorality (examine objects by mouth)
   - perseveration behaviours: get ‘stuck’ on a topic/idea
   - relatively preserved memory and visuospatial skills
   - primitive reflexes
3. ) Pharmacological Management
   - AChEi and memantine are not recommended for use