Perinatal and elderly Flashcards
What suggests depression over dementia in the elderly
Short history
Worried about the memory loss
Biological symptoms
Global memory loss as opposed to short term memory loss
How is alzheimers classified
Based on MMSE score
Mild AD- 21-26
Moderate 10-20
Severe- Less than 10
How is mild/moderate dementia treated
With anticholinesterase inhibitor- donepezil, rivastigmine, galantamine
If these are not tolerated use- memantine
How is severe dementia treated
First line NMDA antagonist- memantine
How would behavioral disturbances be treated in dementia
Sedatives- haloperidol, sodium valproate
Signs of childhood neglect in children
Disinhibited social engagement disorder- indiscriminate sociability where wander off and approach strangers
Reactive attachment disorder- failure to seek and accept comfort from parents
What is leading cause of death in 1 year after pregnancy
Suicide
When do you refer patients postnatally with mental illness
Anxiety- affects day to day function with disproportionate worrying about the baby
Eating disorder- active symptoms
Affective- weight loss, disinterest in baby hypomania
Psychotic- emergency referral
When does postnatal psychosis present
Within first 2 weeks
Risk factor for post partum psychosis
1st pregnancy
Previous episode
Family history
Affective disorders- Bipolar (worse in type 1), schizoaffective
Presentation of postnatal psychosis
Normally anxiety to begin with
Paranoid psychosis
Mania
Rapidly changing mood
Which antipsychotics do women respond better to
Typical
Management of postnatal psychosis
Assess under MHA
Urgently treat with antipsychotics
Aim to keep mother with baby
Admission to mother and baby unit for 1 to 1 nursing supervision
When do baby blues appear
Last up to 48 hours
Occurs within 10 days- peak 4/5 days
What is neonatal adaptation syndrome
When babies are exposed to SSRI/SNRI during pregnancy
Presentation of neonatal adaptation syndrome
Jitteriness
Resp depression
Difficulty feeding and sleeping
Irritability
Best antidepressants in pregnancy
Sertraline is first line
Second line- TCAs
- amitryptylline
- imipramine
- nortriptylline
What is worst thing can do with antidepressants in pregnancy
Stop abruptly- continuing safely
Which antipsychotic should be avoided in pregnancy
Risperidone as risk of cardiac malformation and spontaneous abortion
Bipolar management in pregnancy
If get pregnant switch gradually to an antipsychotic
If pregnant what is advised for depression in BPAD
Olanzapine and fluoxetine
What psychological drugs should be avoided in a breastfeeding woman
Clozapine
Carbamezepine
Lithium
Triad for LBD
Confusion
Visual hallucinations
Parkinsonism signs
How is post natal depression screened for
At first post natal meeting ask 2 questions
- low mood
- anhedonia
If one is yes then undertake the edinburgh postnatal depression scale
Inheritance of huntingtons
Autosomal dominant
Trinucleotide repeat of HTT gene
How does huntingtons present
Choreic moves
Low mood
Memory problems
What happens if give a LBD patinet an anti-psychotic drug
Symptoms worsen
Management of LBD pharmacologically
Offer donepezil or rivastigmine
If not successful or tolerated use galamantine
Pharmacological management of picks disease
None
Poor prognosis factors in alzheimers
Young onset
Male
Behavioural issues
Poor prognosis factors in alzheimers
Young onset
Male
Behavioural issues
Why cant give parkinsonism drugs in LBD
Make hallucinations worse
What is pseudodementia
When depression causes you to slow down cognitively meaning you appear to have dementia
Management of post natal depression
Assess with PHQ9 or edinburgh post natal depression tool
If mild/moderate
- facilitated self help
- if history of severe depression still give medication
If moderate/severe
- offer CBT or antidepressant if does not want CBT and understands risk
- sertraline first line then TCA
What must do before giving SSRI or TCA in post natal depression
Make sure no renal issues with baby or premature if going to breastfeed
Rfx for PND
Younger age
Unwanted pregnancy
Social support poor
Unemployed
Best antipsychotics in pregnancy
Quetiapine
Olanzapine
Chlorpromazine
Haloperidol
Neonatal consequences to look out for of maternal SSRI use
PPHN
Neonatal withdrawal syndrome
Cardiac malformations
Ct change seen in alzheimers
Atrophy of medial temporal lobe (hippocampus)
What neurones are lost in alzheimers
Cholingergic
What are in lewy bodies
Alpha synuclein
Ubiquitin
Where are lewy bodies in parkinsons versus LBD
Parkinsons- substantia nigra
LBD- cortical areas in particular frontal lobe as well as substantia nigra
MRI of lewy body dementia
Same as dementia- atropy of medial temporal lobe
How to differentiate LBD and alzheimers on imaging
Do a DAT scan which shows presence of dopamine trnasportation
It is a lot lower in LBD and parkinsons dementia
Imaging findings of fronto-temporal dementia
CT normal
PET or SPECT (single photon emission computerised topography) will show hypometabolism in frontal lobe
What investigations do for initial dementia
Bloods
- FBC, glucose, U&Es, Ca, B12, folate, HbA1c, lipids, VDRL and HIV
Imaging
- normal practise to do a CT/MRI
Management of dementia
Memory clinic- MDT
- social workers
- OT
- psychologist
- neurologists who may prescribe medication
- enocurage activities to stimulate minds
When do you use memantine
Contraindication/ intolerance to acetylcholinesterase inhibitor in mild/moderate dementia
Can add to acetylcholinesterase inhibitor in moderate dementia
Severe dementia first line
What is NMDA
Glutamate receptor
In dementia how is driving managed
Need to contact DVLA and insurance
Assessed on individual basis
Reviewed annually
What is it when have dementia like symptoms but still able to function independantly
Mild cognitive impairment- cognitive effects still not having significant effect on daily life
How are behavioural and psychiatric disorders in dementia screened for
Neuropsychiatry inventory questionnaire (NPI-Q)
What is most common mental illness in the elderly
Depression
How to treat depression in elderly
CBT less effective but is a possibility
Treat with antidepressants- sertraline or mirtazapine
First line antidepressants for elderly population
Sertraline or mirtazapine
How use antipressants in elderly
Use higher doses
Treat for longer
What is problem of antidepressants in elderly
Increased risk of falls, GI bleeding, hyponatraemia
Dont work if cognitively impaired
Do antidepressants work in dementia
No better than placebo and have side effects
Placebo effect works however
When use antidepressants in dementia
If severe
Needs to be balanced with side effects
What is superior treatment for depression in dementia
ECT
When use ECT for depresssion in dementia
Risk of suicide
Other treatments have failed
Problem of ECT in dementia
Risk of GA
Memory loss
How is depression with psychosis treated in elderly
Anti-depressant with anti-psychotic
ECT if severe
Mania treatment in elderly
Find organic cause
Stop antidepressant
Normal mania treatment
Mood stabiliser for life
How is bipolar depression treated in elderly
Quetiapine or lamotrigine
Management of anxiety in elderly
SSRI/CBT first line
Second line- venlafaxine or mirtazapine second line
In elderly what is most common psychotic disorder diagnosis
Delusional disorder
In the elderly population how does psychosis tend to present
Persecutory delusions
Mutlimodal hallucinations- visual, tactile, auditory
Problems of anti-psychotics in the elderly
Levels are higher in the blood as longer half-life
Increased risk of side effects
How give anti-psychotics in the elderly
Low doses and increase very slowly
Anti-psychotics give in elderly
Amisulpride, olanzapine or risperidone
How do behaviorual and psychological symptoms in dementia present
Agitation
Psychosis
Mood disorder
What need to rule out first as cause of behavioural and psychological symptoms in dementia
Pain
Delirium
Which anti-psychotic used for psychotic symptoms in dementia
Risperidone
What are treatment options for behaviorual and psychological symptoms in dementia
Analgesia
Anti-depressants
Risperidone
Memantine
Do according to presentation
If develop mania as elderly person, what is typical preceeding history
Multiple depressive episodes
If elderly person presents with psychosis symptoms for a few months with no history what is diagnosis
Very late onset schizophrenia like psychosis
Very late onset schizophrenia like psychosis
Occurs in people who live alone and isolated
Partition delusions- whereby substances or people can pass through materials
Management of very late onset schizophrenia like psychosis
Anti-psychotics used but not very effective
Social activities recommended- befriending etc
Why are higher doses of diazepam needed in the elderly
It is fat soluble and higher amounts of fat tissue in the elderly
Presentation of normal pressure hydrocephalus
Ataxia
Incontinent
Dementia
Treatment of normal pressure hydrocephalus
Ventriculo-peritoneal shunt
How long does edinburgh postnatal depression questionnaire ask you to account for
7 days
If man presents with vomiting on donepezil what do
Change to memantine
How is LBD diagnosed compared to parkinsons
Cognitive impairment occurs within 1 year of onset of motor symptoms
What is name of hallucination when see little creatures
Lilliputian
What Edinburgh post natal score suggests a depressive illness
Above 13
Aetiology of fronto-temporal dementia
Loss of neurones in frontal and temporal lobes
CT findings in normal pressure hydrocephalus
Enlarged ventricles
Absent sulci
What is semantic dementia and how present``
A type of frontotemporal dementia
Presents in younger people where struggle to name something you see or hear
First line anti-psychotics in PND
Sertraline and paroxetine
What must be done before starting an anti-cholinesterase
ECG to rule out long QT or bradycardia
Contraindications to anti-cholinesterases
Long QT
Bradycardia under 50
