Psych: Old Age Psychiatry and Dementia

Question 1

Which patients see old age psychiatry?

Answer 1

any person over 65 with mental health problems referred to secondary care services

Question 2

What is Charles Bonnet syndrome? What are the risk factors?

Answer 2

complex visual disturbances/ hallucinations a/w eye disease. Usually hallucinations of faces, children and wild animals.
RF: increasing age, M=F

Question 3

what are the differences with telling whether the diagnosis is delirium or dementia?

Answer 3

delirium: rapid onset, fluctuating, days to weeks (can be months), altered consciousness, impaired attention, immediate recall memory impaired, hypo or hyperactive, disturbed sleep wake cycle (sundowners), usually reversible
dementia: insidious onset, progressive, months to years, clear consciousness, normal attention (unless severe), immediate recall memory usually normal, no psychomotor changes, usually normal sleep wake cycle, irreversible

Question 4

Give some examples of organic and functional mental disorders/causes?

Answer 4

organic: normal ageing, mild cognitive impairment, Alzheimer’s, uncontrolled diabetes, vascular dementia, reduced B12/folic acid (also macrocytic anaemia sign), reduced thiamine, meds eg benzodiazepines can cause memory loss
functional: depression (pseudo-dementia)

Question 5

What are the features of the MMSE?

Answer 5

maximum score is 30 points. a score of 20-24 suggest mild dementia, 13-20 suggests moderate dementia, and less than 12 indicates severe dementia

Question 6

What tests are done in screening confusion (to rule out delirium/reversible causes of confusion)?

Answer 6

Blood tests
o FBC (infection, anaemia [confusion], malignancy)
o U&Es (hyponatraemia [confusion], hypernatraemia)
o LFTs (liver failure with secondary encephalopathy)
o Coagulation/INR (intracranial bleeding)
o TFTs (hypothyroidism [depression & similar presentation])
o Calcium (hypercalcaemia)
o B12 + folate/haematinics (B12/folate deficiency [cognition problems])
o Glucose (hypoglycaemia /hyperglycaemia)
o Blood cultures (sepsis)
Urinalysis
o UTI is a very common cause of delirium in the elderly
o Positive urine dipstick without clinical signs is not satisfactory
o Look for other evidence (increase WCC, suprapubic tenderness, dysuria, offensive urine, positive urine culture
Imaging
o CT head – concern about intracranial pathology (bleeding, ischaemic stroke, abscess)
o Chest x-ray – may be performed if there is concern about lung pathology e.g. pneumonia, pulmonary oedema)
ECG required for some dementia meds

Question 7

What is the definition of delirium?

Answer 7

acute, transient and reversible state of confusion, usually the result of other organic processes eg infection, drugs, dehydration

Question 8

What are the 2 types of delirium?

Answer 8

hyperactive - typical: agitation, delusions, hallucinations, wandering, aggression
hypoactive - atypical and often missed or confused with depression; lethargy, slowness, excessive sleeping, inattention

Question 9

what are the causes of delirium?

Answer 9

CHIMPSPHONED
C - constipation
H – hypoxia/hydration
I – infection
M – metabolic disturbance inc dehydration
P - pain
S - sleeplessness
P – prescriptions/polypharmacy
H – hypothermia/pyrexia
O - organ dysfunction
N - nutrition
E - environmental changes* - inc. emotions/depression/anxiety
D - drugs (over the counter, illicit, alcohol and smoking)

Question 10

What is the first line diagnostic tool in delirium?

Answer 10

SQID: single question in delirium (SQID)
more confused than normal? yes or no
positive > collateral history

Question 11

After history and cognitive assessment of suspected delirium, a thorough clinical exam should be performed including what?

Answer 11

• Vital signs (fever if infection, low SpO2 in pneumonia)
• Level of consciousness (GCA/AVPU) – clouding of consciousness often present in delirium
• Evidence of head trauma
• Sources of infection
• Asterixis (uraemia/encephalopathy)
• Confusion screen (bloods, urinalysis, imaging)

Question 12

what is the definitive, supportive and medical management of delirium?

Answer 12

Definitive: Identify and treat the underlying cause

Supportive
* Consistent care team, ensure access to aids, glasses, hearing and walking sticks, Enable independent activity where possible
* Access to a clock and other orientation reminders, have familiar objects (e.g. photos/clothes), involve friends and family, control surrounding noise, adequate lighting and temperature

Medication
* Avoid unnecessary medications where possible, can worsen delirium
* Wandering is not absolute indication for sedation
* Lorazepam is the first line benzo (0.5mg starting dose – 1mg) due to its rapid onset and short half life
o MAX DOSE is 2mg in 24 hours
* If already on benzos or at risk of respiratory depression then haloperidol is first line option (at a low dose in the elderly – 0.5mg)
o Contraindicated in parkinsons, dementia with LB or prolonged Qtc

Question 13

What is the prognosis of delirium and what is the prevention?

Answer 13

post discharge: behaviours can continue for up to 6 months after the cause has been treated - make family and carers aware
prevention: avoid drugs known to preciptate delirium (opiates and benzos), identify patients at high risk and observe for early signs, assess pain control and drugs, employ supportive and environmental management approaches for all patients, regardless of delirium risk

Question 14

Is dementia a normal part of ageing? What is the criteria to be classed as dementia? What is dementia associated with (biologically)?

Answer 14

it is NOT a normal part of ageing
must be of at least 6 months duration and affect activities of daily living
associated with decreased amount of acetlycholine in the brain

Question 15

What is the rule of 1/3 of cognitive impairment with dementia patients?

Answer 15

1/3 get better
1/3 stay the same
1/3 develop dementia

Question 16

What are the 5 A’s of dementia?

Answer 16

amnesia - memory impairment
agnosia - recognition
apraxia - motor skills eg dressing
aphasia / agnosia - speech and language
associated behaviours - BPSDs

Question 17

What s the role of the temporal lobe?

Answer 17

hearing
language comprehension (wernicke’s area)
memory / information retrieval
facial recognition
feelings

Question 18

What is the role of the frontal lobe?

Answer 18

motor control (premotor cortex)
problem solving (prefrontal area)
speech production (broccas area)
thinking, planning, emotions, behavioural control, decision making

Question 19

What is the role of the parietal lobe?

Answer 19

body orientation / sensory discrimination / visuospacial
touch perception (somatosensory cortex)

Question 20

In which dementia are BPSDs most common?

Answer 20

fronto-temporal dementia
can occur in all dementia subtypes but don’t occur in everyone

Question 21

How do you tell the difference between delirium and BPSDs?

Answer 21

differentiate with timeline (acute vs progressive) and baseline level with a collateral history

Question 22

what are the behavioural and psychological symptoms of BPSDs?

Answer 22

behavioural:
Wandering
Restlessness
Pacing
Agitation
Disinhibition
Screaming
Physical aggression
Swearing
Apathy
Repetitive

psychological:
Anxiety
Misidentification
Depressed
Insomnia
Delusions (depth perception issues, forget where they place things and think people are “stealing” from them)
Hallucinations

Question 23

What are the causes of BPSDs?

Answer 23

PINCH ME
Pain

INfection

Constipation

Hydration

Medication

Environmental

Question 24

How do you assess BPSDs?

Answer 24

Behavioural assessment –ABC
o Antecedents – what happened before?
o Behaviour – what was the behaviour?
o Consequences – what was the consequence?
Physical assessment - e.g. are they in pain?
Mental state assessment to consider alternative causes and treatments – e.g. depression or sleep disturbance
Collateral history
Look at the mnemonic PHONED as a guide for assessing causes of symptoms in people with dementia
Refer if necessary to Medicine for the Elderly or Old Age Psychiatry

Question 25

What are the differentials of BPSDs?

Answer 25

BIO: pain, delirium, constipation, dehydration, stroke etc.
PSYCHO: depression, anxiety, deterioration of dementia
SOCIAL: links to environmental changes, approach of staff

Question 26

What is the management of BPSDs?

Answer 26

Treat the cause
If necessary refer to medics
Environmental modification and practical management (e.g. education for family / staff)
Medication as a last resort
Memantine
o Antipsychotics
 Only Risperidone is licensed for management of agitation
 Side effects are greater in older people
 Avoid using it if possible due to the associated risks:
 Parkinsonism
 Falls
 Stroke risk (2-3 times baseline risk)
 Cardiovascular risks
 Death
 If it is used then the lowest possible dose should be prescribed for a time limited period
 Often inappropriately prescribed to ‘control’ BPSD

Question 27

What are the differentials of dementia?

Answer 27

D – drugs, delirium – drugs causing confusion e.g. opitates/steroids
E – emotions/depression – mood causing them to be slow/deteriorate
M - metabolic disorders - U&E, infections etc
E - eye and ear imparitment – affect concentration and ability to retain information
N - nutritional disorders - underweight
T - tumours, toxins, trauma – brain tumors or anything poisoning them
I - infections - delirium (can be superimposed on dementia so treat delirium and see if dementia persists)
A - alcohol, arteriosclerosis

Question 28

In what circumstance can you not diagnose dementia?

Answer 28

CANNOT diagnose dementia on top of depression > treat the depression first

Question 29

What is the ICD-10 definition of dementia?

Answer 29

It is a syndrome due to disease of the brain, usually of a chronic or progressive nature. There is a disturbance of multiple higher cortical functions, including a decline in memory and learning new information. No clouding of consciousness.
It is also accompanied by deterioration in judgment and thinking, processing of new information, emotional control, social behaviour or motivation. For more than 6 months

Question 30

What does ICD-10 class as mild, moderate and severe dementia?

Answer 30

mild: memory loss is sufficient to interfere with everyday activities but they are able to live independently
moderate: memory loss is a seriosu handicap to independent living and only highly learned or very familiar material is retained. They are unable to function without the assistance of another in daily living.
severe: there is a complete inability to retain new information. There is a virtual absence of intelligible ideation. The mind can no longer tell the body what to do.

Question 31

What is the most common type of dementia?

Answer 31

Alzheimer’s

Question 32

What is the pathophysiology of Alzheimer’s? What are the 4 pathologies?

Answer 32

Progressive degeneration of the cerebral cortex (widespread cortical atrophy)
Affected neurons contain amyloid plaques, neurofibrillary tangles (tau) & produce less acetylcholine
1. amyloid plaques
2. cerebral atrophy - most pronounced in the medial temporal lobes (hippocampus is here which is responsible for memory)
3. neurofibrillary tangles
4. reduced levels of acetylcholine

Question 33

What are the RFs of Alzheimer’s?

Answer 33

Age! W>M
Genetics:
ApoE is a gene related to late-onset Alzheimer’s
APP (amyloid precursor protein): found on chromosome 21 (3 of them in Downs Syndrome) – APP produces amyloid plaques which is a feature of AD. Increased plaques = increased risk of AD

Modifiable: social isolation, risk-factors associated with vascular disease (smoking/alcohol, hypercholesterolaemia, HTN, obesity & diabetes), head injury

Question 34

What is the overall feature of Alzheimer’s?

Answer 34

insidious and gradual onset with progressive cognitive decline

Question 35

what are the early features of Alzheimer’s?

Answer 35

memory loss, leading to confusion
e.g. forgetting names of people & places, difficulty finding the words for things, getting lost mid-sentence, inability to remember recent events, getting lost, misplacing things, forgetting appointments

Question 36

what are the intermediate features of Alzheimer’s?

Answer 36

Difficulties with language (struggling to follow a conversation or repeating themselves)
Visuospacial skills – problems judging distance, stairs, parking, 3D
Apraxia (the inability to perform learned movements) – need to be given step by step instructions
Problems with planning & decision making
Orientation – confused or losing track of the day or date

Question 37

What are the features of Alzheimer’s in the later stages?

Answer 37

Psychiatric: depression, hallucinations, delusions, insomnia
Behavioural: disinhibition, aggression, agitation, irritable
Wandering & disorientation
Less aware of what is happening around them
Apathy
Altered eating habits, difficulty with walking, increasing frailty
Urinary incontinence
Expressive dysphasia

Question 38

What are the pathological findings of Alzheimer’s?

Answer 38

• Cerebral atrophy on MRI – most pronounced in the medial parietal temporal lobe (predominantly involves in memory)
• Vascular ischaemic changes
• Widened sulci and dilated ventricles on CT/MRI
• Senile/amyloid plaques deposition. Extraneuronal deposits of amyloid beta protein. Plaques cause inflammation  cell death
• Neuro-fibrillay tangles. Intraneuronal hyperphosphorylated tau protein, disrupts cell functions
• Acetylcholine levels reduced (loss of cholinergic neurons

Question 39

What are the investigations of Alzheimer’s?

Answer 39

1. Comprehensive history & physical exam:
2. Medication review: are there any contributing factors?
3. Formal screen for cognitive impairment: e.g. MMSE/ GPCOG – neuropsychodynamic test can be done by psychologist if borderline score on the ACE
4. Exclude reversible organic causes: rule out infection (urine dip, inflammatory markers, FBC), metabolic (TFT, U+Es, calcium)
5. Consider MRI, cultures, CXR
6. Very important to identify depression!!

Question 40

What are the NICE general managements?

Answer 40

Offer a ‘range of activities to promote wellbeing that are tailored to the person’s preference’ – e.g. group cognitive stimulation therapy for those with mild & moderate dementia. E.g. + Group reminiscence therapy
Emotional and carer support
Familiatiry – photos in room same carers etc
Calm, well lit environment,
Communicate calmly and clearly
DO - talk slowly, ask short questions, stay calm
DO NOT - take offence, blame, argue etc.

Question 41

What is the medical management of Alzheimer’s?

Answer 41

mild-moderate: Acetylcholinesterase inh eg donezepil, rivastigmine or galantamine
moderate-severe: memantine (NMDA) > added on top of donezepil when symptoms worsen

Question 42

What are the side effects of acetycholinesterase inhibitors?

Answer 42

Decreases anxiety, increases motivation, concentration, ADLs
(Cholinergic side effects) Diarrhoae, incontinence, nausea, vomiting, headache, loss of appetite, dizziness, sleep disorders, GI disturbance = so start at a low dose & titrate up opposite of can’t see, pee, climb a tree
Severe side effects: Slows HR (less so for galantamine), decreases appetite, increased weight loss

Question 43

What are the contraindications of acetylcholinesterase inhibitors?

Answer 43

heart block, bradycardia, active asthma/COPD/bronchitis (more frequent use of inhaler/beta blockers contraindicated), active peptic ulcer unless on PPI (as risk of bleeding), epilepsy (lowers seizure threshold)

Question 44

When should acetylcholinesterase inhibitors be given?

Answer 44

Taken in the morning – not on an empty stomach (GI disturbance). May make people sleepy, in which case take it at night

Question 45

What are the side effects of memantine?

Answer 45

Side effects (less common/severe): Dizziness, constipation, SOB, headache, sedation (taken at bed time), increased BP
Renal function needs monitoring, esp eGFR – must be >49 for more than 10mg
Can affect INR (check if on warfarin)

Question 46

Which meds should be avoided in Alzheimer’s?

Answer 46

Avoid anti-cholinergic medications (worsen cognitive impairment) E.g. antihistamines, anti-psychotics & tolterodine

Question 47

What is the second most common type of dementia in over 65s?

Answer 47

vascular dementia

Question 48

What is the onset of vascular dementia?

Answer 48

sudden onset with stepwise deterioration
fluctuating day to day

Question 49

What makes vascular dementia different to Alzheimer’s with regards to memory?

Answer 49

vascular dementia has motor and sensory defects alongside memory decline
AD is memory only

Question 50

What are the RFs for vascular dementia?

Answer 50

high BP, smoking, coronary artery disease, hypercholesterolaemia, diabetes, strokes (lots of small events eg lacunar infarcts which accumulate to cause vascular dementia), M>W, age

Question 51

What are the symptoms of vascular dementia?

Answer 51

problems with planning, organising, concentrating, memory, language, visuospatial skills; difficulties following steps; slower speed of thought

Question 52

How do you manage the RFs of vascular dementia?

Answer 52

statins, antihypertensives, diabetes

Question 53

What are the features of dementia with Lewy bodies?

Answer 53

alpha-synuclein forms into clumps inside neurons (aggregation of alpha-synuclein), starting in areas of the brain that control aspects of memory and movement

Question 54

What is the triad of Lewy Body dementia?

Answer 54

REM sleep disorder, history of falls (secondary to motor problems) and hallucinations (often of small, non-threatening people/animals [Lilliputian hallucinations])

Question 55

What are the RFs of Lewy body dementia?

Answer 55

few RFs other than age - no clear family history

Question 56

What are the clinical features of Lewy Body dementia?

Answer 56

• Progressive ALZ and Parkinsons symptoms
• Early – attention/alertness issues which fluctuate throughout the day
• Visual hallucinations (2/3rds) (more than AD/VD) and delusions
• Parkinsonism (up to 70%) to differentiate between two = what came first the parkinsonism or cognitive decline
  If the memory issues more than 12 months after movement issues - PDD
  If memory issues within 12 months of movement issues (same sort of time) - LBD
  Tactile hallucinations common/”happy” one – animals and babies etc
• Risk of falls!
• Fluctuating consciousness
• REM sleep disorders
• 70% have systematised delusions, 40-50% have a depressive episode, risk of falls, syncope
• As it progresses, day-day memory, behaviour challenges and walking gets worse

Question 57

What will the SPECT (DaT)/PET scan show with Lewy Body Dementia?

Answer 57

reduced DA (reduced striatal uptae of ligand for presynaptic dopamine transporter site in LBD but not AD)

Question 58

What is the management of Lewy Body dementia?

Answer 58

Acetylcholinesterase & memantine are licenced (Rivastigimine) for challenging behaviours (for LBD and Parkinson’s!)
Non-drug management should be tried first – S&L therapy
Avoid antipsychotics!!! > can make parkinsonism much worse. Quetiapine sometimes used with great caution
Treatment is notoriously difficult and is a fine balance between PD and psychotic symptoms
PD and LBD are caused by low levels of DA and are treated by boosting DA - psychosis is caused by high levels of DA and is treated by reducing it
Neurological symptoms may worsen with neuroleptics
psychological interventions are vital in helping manage the condition

Question 59

What is the second most common cause of dementia in those UNDER 65s (AD is first)?

Answer 59

frontotemporal dementia (Pick’s disease)

Question 60

What are the key features of frontotemporal dementia?

Answer 60

Usually onset <65 years
Insidious onset
Relatively preserved memory
Personality change & social conduct issues
2-10 years prognosis
Later stages similar to later stages of Alzheimer’s dementia

Question 61

what are the 3 subtypes of frontotemporal dementia?

Answer 61

1. behavioural variant FTD (PICKS, 2/3rds) - frontal lobe involvement prominent
2. progressive non-fluent aphasia (CPA) - slow and progressive (2-3 years); memory etc preserved in early stages
3. semantic dementia - slow and progressive (2-3 years); memory etc preserved in early stages. peak age of onset = 55-56 years

Question 62

what are the symptoms of the 3 types of frontotemporal dementia?

Answer 62

1. behavioural:
   lose their inhibitions – act in socially inappropriate ways
   lose interest in people and things – lose motivation but are not sad unlike in depression
   lose sympathy or empathy
   show competitive, compulsive or ritualised behaviours
   crave sweet or fatty foods, increased appetite, lose table etiquette – puts random objects into mouth
   perseveration behaviours
2. progressive non-fluent aphasia (CPA)
   Slow, hesitant speech
   Errors in grammer
   Impaired understanding of complex sentences, but not single word
3. semantic dementia
   Asking the meaning of familiar words (e.g. what is knife?)
   Trouble finding the right word
   Difficulty recognising familiar people or common objects

Question 63

What is the histology of frontotemporal dementia?

Answer 63

• Picks (20-30%) – marked transcorticol ASTROGLIOSIS, Pick cells (characteristic ballooned neurons) and Pick bodies (tau positive neuronal inclusions)
• Also atrophy of frontal and temporal lobes and neurofibrillary tangles
• Non-Picks – spongiform microvacuolation, only mild gliosis
• ‘Knife-blade atrophy’, gliosis & neuronal loss of the frontal & temporal lobes (younger indivisual so generally more accurately seen

Question 64

What is the management of frontotemporal dementia?

Answer 64

Avoid AChE inhibitors & memantine!!
Treat the presenting symptoms, psychosocial interventions
Speech and language therapy
Some evidence in using SSRI to improve disinhibition
Risperidone is the only antipsychotic licensed for persistent aggression/distress. Use at lowest dose for shortest time (up to 6 weeks)
Supportive care + benzos + SSRIS = for agitation

Question 65

What are the differences between depression and dementia?

Answer 65

Shorter history, rapid onset
Biologcal symptoms e.g. weight loss, sleep disturbance
Patient worried about poor memory (insight)
Mini-mental test score is variable
Global memory loss (dementia characteristically causes recent memory loss)

Question 66

What is normal pressure hydrocephalus? and what is the treatment?

Answer 66

IE wet, wobbly and weird
A reversible cause of dementia that can be seen in predominantly elderly patients.
Due to impaired absorption of CSF at the arachnoid villi  increased ICP  ventriculomegaly. This can be triggered by an insult such as a bleed or head injury.
* Triad of: urinary incontinence, dementia and gait abnormality which develops over several months.
* Neuro-imaging can appear similar to Parkinson’s disease, but being unresponsive to L-DOPA can be used as a sign of normal pressure hydrocephalus.
o Enlarged ventricles with absent sulci [as they are compressed by the sulci] (PD = enlarged ventrciels and prominent sulci)
* Treatment in patients fit for surgery is ventriculo-peritoneal shunting, otherwise they may be managed with conservative treatment and repeated CSF taps.