Psychiatry of old age Flashcards
1
Q
prevalence of mental health disorder in the elderly
A
20-25%
2
Q
what is the most common mental health disorder in the elderly
A
depression (10.3%)
3
Q
prevalence of dementia in those over 65 and over 80 years old
A
- 5% > 65 years old
- 20% > 80%
4
Q
methods of cognitive testing
A
- Folestein’s Mini mental state exam
- montreal Cognitive Assessment (MOCA)
- Addenbrooke’s Cognitive Assessment (ACE-R)
5
Q
components of the mental state examination
A
- Appearance
- Behaviour
- Speech
- Mood
- Affect
- Thoughts
- Perceptions
- Risks
- Cognition
- Insight
6
Q
investigations that should be done
A
- blood tests
- ECG
- EEG
- X-rays
- Neuroimaging - CT scans, MRI scans, PET scans
- Toxin screens
- Others
7
Q
depression in later life
A
- most common mental illness in > 65s
- it is not a normal consequence of aging
- sadness/ grief are normal responses to life events - e.g bereavement, loss of social status, change in role, transition to assisted living
- associated with;
1. Unnecessary suffering
2. Impaired functional status
3. Increased mortality
4. Increased use of healthcare resources
5. Under-diagnosed and treated
rates;
- 2-10% in community settings
- 30% of hospitalized older people
- 40% of patients with cancer/MI
8
Q
Risk factors for depression in the elderly
A
- family history less likely
- females > males
- social isolation
- widowed/ divorced/ separated
- lower socioeconomic status
- co-morbid physical ill health
- Pain
- insomnia
- impaired cognitive or functional status
9
Q
Nursing home residents and depression
A
- cognitive impairment/ dementia increases the incidence and reduces the detection of depression
- prevalence in Nursing home:
— 10-20% cognitively intact
— 50-70% cognitively impaired
10
Q
physical illness and depression in the elderly
A
- risk of depression increases with;
1. recent onset of physical illness
2. Greater severity
3. Functional impairment
4. limited mobility
5. Poor pain management
6. Multiple illnesses - can be the first presentation of stroke/ CVA. diabetes, hypothyroidism
11
Q
Suicide in the elderly
A
- depression is a major risk factor
- less frequent attempts
- more likely to be successful
- highest rate - caucasian men > 65 years old
- risk factors for suicide;
1. hopelessness, insomnia, agitation, impaired concentration, psychosis, alcohol/drug misuse
2. Older age, male sex, living alone, bereaved
3. Physical illness, pain and previous attempts
12
Q
diagnosis of depression in the elderly
A
- history, informant history and thorough MSE and risk assessment
- MMSE and cognitive assessment
- physical work-up including bloods, scans etc to rule out organic illness
13
Q
depression in the elderly can present in an atypical fashion
A
- men - more likely to present with anger, irritability, withdrawl, apathy, and alcohol misuse
- women - more likely to acknowledge sadness
- agitation, anxiety, physical complaints prominent
- biological symptoms
- pseudo-dementia
14
Q
psychotic depression in the elderly
A
- more common in elderly than general adult population
- most severe form of depression - symptoms can be difficult to treat and more liklely to relapse
- delusions - mood congruent. Poverty, guilt, worthlessness, inadequacy, nihilistic. Can be somatic/ paranoid
- hallucinations are uncommon
15
Q
Management of depression in the elderly
A
- Biological
- SSRIs first line, often sertraline, escitalopram, Citalopram
- venlafaxine and Mirtazapine are often used as a second line agents
- may require augmentatino with a second antidepressant, atypical antipsychotics, lithium
- consider ECT in treatment resistance, psychotic depression or when a rapid response is needed
- minimum 6-9 months after remission of symptoms - Psychological
- CBT
- interpersonal therapy
- less often psychodynamic or psychoanalytical approaches
- Bereavement counselling or supportive psychological therapies
- other psychotherapy if more appropriate - systemic/ family therapy - Social
- day centres - structured and supported social activities
- home help - manage ADLs, promote independence, dignity and remain in their own home
- social groups - active retirment, Men’s shed initiative, clubs
- respite if necessary
16
Q
anxiety disorders in the elderly
A
- 5-15% prevalence
- most cases treated in primary care
- presence of an anxiety disorder increases risk of development of depression by 20%
- management is similar as for young adults:
— treat co-morbid depression
—- anxiety management skills, mindfulness
— CBT, social interventions
—- notably: avoid benzodiazepines – sensitivity to side effects
17
Q
psychosis in the elderly - classification
A
- Old psychosis - i.e graduates of general adult population
- New psychosis - late onset paraphrenia/ Psychotic spectrum disorder. Arises between 40-59
- New psychosis - very late onset Schizophrenia (VLOSP) > 60 years
18
Q
Psychotic spectrum disorders
A
- most likely to be diagnosed as delusional disorder
- presence of delusional beliefs often systematized and quite elaborate. Content is often plausible and non-bizarre
- significant emotional investment in belief system
- relative absence of major mood symptoms or other psychotic symptoms
- prevalence 5-6% population
- more likely to be female
- premorbid personality traits: poor adjustment, 45% show paranoid/ Schizoid personality traits. Tend to have poor relationships but good educational and occupational adjustment
- often chronic and longstanding. Resistant to treatments. Antipsychotics may attenuate intensity of beliefs/ preoccupation with them
- psycho-social supports and risk reduction strategies
- treat co-morbidities
19
Q
Very late onset Schizophrenia
A
- > 60 years old
- rare: <1 % of population
- 10% of elderly patients admitted to psychiatric hospitals
- lower risk of family history in first degree relatives (3.4% vs 5.8% younger schizophrenia patients)
- premorbid personality: poor adjustment, 45% show paranoid/ schizoid personality traits. tend to have poor relationships but good educational and occupational adjustement
- sensory impairments increase risk of VLOSP
- more likely to live alone, and may have had early life traumatic experiences
20
Q
clinical features of very late onset schizophrenia
A
- similar to early onset schizophrenia
- paranoid persecutory delusions are most common (90%)
— often partition delusions involving neighbours (66%)
— others: misidentification, religious, hypochondriacal - auditory hallucinations in 75%
- visual hallucinations 13%
- similar brain changes earlier onset schizophrenia
- chronic course - can be relapsing/ remitting (compliance)
- better prognosis than in younger adults
- suicide risk similar to younger adults
21
Q
presentation of delirium
A
- acute onset (over hours to days)
- decline in attention - i.e ability to focus, perception, and cognition
- the change in cognition must not be better accounted for by dementia
- fluctuating pattern
22
Q
differential diagnosis of delirium
A
- Dementia
- irreversible, and not associated with fluctuating levels of consciousness
- need knowledge of baseline level of cognitive function - Depression
- particularly in hypoactive delirium - Psychosis
- may overlap, but in general consciousness and cognition not impaired
23
Q
risk factors for delirium
A
- age > 80 years
- Extreme physical frailty
- Multiple medical comorbities
- Infections (RTI, UTI)
- Polypharmacy
- sensory impairment
- Metabolic disturbances
- long bone fracture
- General anaesthetic
- Dementia
24
Q
causes of delirium
A
- infections
- Withdrawl (drugs, alcohol)
- Acute metabolic disturbance (acidosis, ARF)
- trauma (acute pain, constipation)
- CNS pathology
- Hypoxia
- deficiencies (B12, thiamine)
- endocrine disturbance
- Acute vascular
- Toxins (drugs prescribed/ illicit)
- heavy metals
25
Q
delirium diagnostic criteria
A
- impairment of consciouness and attention (on a continuum from clouding to coma; reduced ability to direct, focus, sustain, and shift attention
- global disturbance of cognition (perceptual distortions, illusions and hallucinations - most often visual impairment of abstract thinking and comprehension, with or without transient delusions, but typically with some degree of incoherence; impairment of immediate recall and of recent memory but with relatively intact remote memory; disorientation for time as well as, in more severe cases, for place and person)
- psychomotor disturbances (hypo- or hyperactivity and unpredictable shifts from one to the other; increased reaction time; increased or decreased flow of speech; enhanced startle reaction)
26
Q
overview of delirium
A
- a transient global disorder of cognition
- a medical emergency
- affects 20% of patients on general medical and surgical wards
- affects 30% of older medical patients
- associated with increaed mortality, increased care needs, failure of rehabilitation and prolonged hospital stay
27
Q
Delirium: ICD-10
A
- an etiologically non-specific syndrome characterized by concurrent disturbance of consciousness and attention, perception, thinking, memory, psychomotor behaviour, emotion and the sleep-wake cycle
- most common > 60 years old
- transient and of fluctuating intensity
- most recover within 4 weeks or less, but cases may last up to 6 months
28
Q
treatment - psychosis in the elderly
A
- therapeutic rapport and alliance
- exclude cognitive/ medical disorders
- Bio-psycho-social approach
- treatment similar to younger adults, but not susceptibility to anti-psychotic side effects
- mainstay of pharmacological treatment is with antipsychotic medications, atypical antipsychotics are first line agents; olanzapine, risperidone, quetiapine, Arpiprazole, amisulpride
- typical antipsychotics are sometimes used
- doses are typically 50% lower than general adult population with slower titration schedules
- psychological therapy
- nursing care
- social work and occupational therapy interventions
29
Q
definition of dementia
A
- syndrome due to disease of the brain, usually of a chronic or progressive nature, in which there is disturbance of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgement
- consciousness is not clouded
- impairments of cognitive function are commonly accompanied, and occasionally preceded, by deterioration in emotional control, social behaviour, or motivation
- dementia produces an appreciable decline in intellectual functioning, and usually some interference with personal activities of daily living, such as washing, dressing, eating, personal hygiene, excretory and toilet activities
30
Q
subtypes of dementia
A
- alzheimers
- vascular dementia
- Lewy body dementia
- Dementia in Parkinson’s disease
- frontotemporal dementia
- Picks disease
- Dementia in CJD
- progressive supra-nuclear palsy
31
Q
dementia - clinical features
A
- cognitive:
- memory deficits: STM - LTM - Universal disorientation and amnesia
- language deficits: receptive and expressive dysphasia, Lexical anomia
- apraxia
- agnosia
- impaired visuo-spatial function and executive function - Behavioural
- apathy, agitation, aggression, pacing, wandering, non specific goal directed behaviours, impulsivity, disinhibition, repeated vocalisations, sleep disturbance - Psychiatric
- depression
- anxiety
- paranoia
- delusions
- hallucinations
- obsessions
- compulsions
- personality changes - Progression
- increasingly agitated, emotional outbursts, night pacing and insomnia, wandering - terminal phase
- profound disorientation and amnesia, incontinence
32
Q
behavioural and psychological symptoms of dementia (BPSD)
A
- amotivation and apathy
- agitation, restlessness and pacing
- aggression
- disinhibition, sexualised behaviour
- repeated vocalisations and screaming
- shadowing
- sleep disturbance
- sun-downing
- wandering
- anxiety
- depression (20%)
- Psychotic symptoms (auditory and visual hallucinations, delusions, association with rapid decline, average survival after onset 8 yrs)
33
Q
risk factor and protective factors for alzheimer disease
A
- risk factors
1. proven: age, Down syndrome, Apo e4 allele
2. likely: female, head injury, postmenopause
3. possible: family history of parkinsons, vascular risks - protective factors
1. Apo e2 Allele
2. Possible: smoking, NSAID use, estrogen, premorbid education
34
Q
Pseudodementia
A
- apparent cognitive impairment associated with psychiatric illness
- most commonly depression (50-100%)
- four criteria for a diagnosis;
1. intellectual impairment in a person with a mental illness
2. features of presentation are similar to those seen in a CNS disorder
3. cognitive deficits are reversible
4. no known neurological condition which could otherwise account for the depression
35
Q
Investigations - dementia
A
- clear and detailed history
- collateral history
- investigations
- FBC
- U and E
- LFT
- TFT
- B12
-folate
- ferritin
- fasting glucose and cholesterol
- iron studies
- VDRL and HIV
- MSU
- CT brain
- MRI brain
- PET scans or other functional imaging - safety assessment
- driving
- home environment
- neglect
- fire hazard
- vulnerability to exploitation
- falls
drug and alcohol use/ medication use
36
Q
cognitive testing - dementia
A
- MMSE: brief bedside for global function. Covers orientation, Attention, memory, concentration, Praxis, gnosis, language. SE status, age, education can affect score. 24/30 cut off widely used
- Clock drawing test - executive function
- MOCA: similar to MMSE except more focus on frontal and executive function. 26/30 cutt off widely used
- ACE - addenbrooke’s cognitive examination. More in-depth tool. >88/100 score considered normal
- Neuropsychological test battery
37
Q
management of dementia
A
- manage lifestyle and risk factors: stop smoking, stop/reduce alcohol, manage cholesterol, hypertension and any vascular risk factors
- cholinesterase inhibitors for mild to moderate severity e.g donepezil, rivastigmine, and galantamine
- memantine for moderate to severe illness
- cholinesterase inhibitors and memantine aim to delay progression, improve cognitive symptoms and sometimes reduce behavioural disturbance. they do not reverse the illness
- treat co-morbidities especially mood/anxiety features, manage physical pain/comfort, manage concurrent delirium
- non-pharmacological strategies are first line in managing behavioural disturbance
38
Q
management of dementia - psychological
A
- psycho-education - family, carers
- memory aids
- behavioural strategies for management of behavioural disturbance
- supportive psychotherapy for families, carers
- reminiscence therapy
- multisensory therapy
- animal therapy
- massage
- music/ dancing
39
Q
management of dementia - social
A
- support groups for families/ carers
- day centres/ social groups for people with dementia -e.g alzheimer society ireland
- placement -e.g home - need for home help, meals on wheels etc
- respite
- nursing home care
40
Q
Pharmacological treatments for behavioural and psychological symptoms of dementia
A
- If BPSD is severe and refractory to non-pharmacological measures
- consider the risks of treatment vs non-treatment
- define target symptoms e.g agitation, aggression, paranoia
- consider form i.e tablet or liquids, swallow issues and choking
- atypical antipsychotics in low and divided doses for anxiety, agitation, aggression, paranoia, and psychosis e.g quetiapine, risperidone, Olanzapine. risk of falls, excessive sedation, worsening confusion, EPSEs and raised incidence of CVAs and cardiac events
- Gabapentin, Carbamezapine, valproate - agitation, aggression, emotional lability
- trazadone - agitation, insomnia, anxiety, mood
- hypnotics, melatonin - short term management of insomnia
- benzodiazepines - short term management of anxiety and agitation. (Caution with falls, oversedation, and confusion) Sometimes benzodiazepines have a paradoxical effect - worsen agitation and disinhibition
41
Q
delirium: ICD-10 classification
A
- an etiologically non-specific syndrome characterized by concurrent disturbances of consciousness and attention, perception, thinking, memory, psychomotor behaviour
- most common > 60 years old
- transient and fluctuating symptoms
- most recover within 4 weeks or less, but cases may last up to 6 months
42
Q
delirium diagnostic criteria
A
- impairment of consciousness and attention (on a continuum from clouding to coma; reduced ability to direct focus, sustain and shift attention)
- global disturbance of cognition (perceptual distortions, illusions and hallucinations - most often visual; impairment of abstract thinking and comprehension, with or without transient delusions, but typically some degree of incoherence; impairment of immediate recall and of recent memory but with relatively intact remote memory; disorientation for time as well as, in more severe cases, for place and person
- psychomotor disturbances (hypo- or hyperactivity and unpredictable shifts from one to the other; increased reaction time; increased or decreased flow of speech; enhanced startle reaction
43
Q
delirium extra info
A
- transient global disorder of cognition
- a medical emergency
- affects 20% of patients on general medical and surgical wards
- affects 30% of older medical patients
- associated with increased mortality, increased care needs, failure of rehabiliation and prolonged hospital stay
44
Q
presentation of delirium
A
- acute onset (over hours to days)
- decline in attention - ability to focus, perception and cognition
- the change in cognition must not be better accounted for by dementia
- fluctuating pattern
45
Q
differential diagnosis for delirium
A
- dementia
- irreversible, and not associated with fluctuating level of consciousness
- need knowledge of baseline level of cognitive function - depression
- particularly in hypoactive delirium - Psychosis
- may overlap, but in general consciousness and congition not impaired
46
Q
risk factors in the elderly for delirium
A
- age >80 years
- extreme frailty
- multiple medical comorbidities
- Infections (RTI, UTI)
- Polypharmacy
- sensory impairment
- metabolic disturbances
- Long bone fracture
- General anaesthetic
- dementia
47
Q
Causes of delirium
A
- infections
- withdrawl (drugs, alcohol)
- Acute metabolic disturbance (acidosis, ARF)
- Trauma (acute pain, constipation)
- CNS pathology
- hypoxia
- Deficiencies (B12, thiamine)
- Endocrine disturbance
- acute vascular
- Toxins (i.e drugs prescribed/illicit)
- heavy metals
