Psychogeris Flashcards
Dementia sx
Alzheimers - memory impairment plus >1 of aphasia/apraxia/agnosia/executive deficit in functioning
Vascular
Lew body - spontaneous features of parkinsonism, vivid VHs, fluctuating consciousness, sensitive to antipsychotics, falls and syncope
MS
Depression vs pseudodementia
ABC analysis
Antecedents - triggers, time of day, sporadic vs pattern e.g towards specific staff member or resident
Behaviour - specific description, length of episode, other BPSD such as disinhibition, confusion, self harm, wandering, absconding
Consequences - how does staff respond - punishment vs positive vs negative reinforcement
-consistency of response
-medications and effectiveness
-environmental modification
-psychological modification strategies used
Causes of behaviour
- Medical causes - fever, pain, constipation, UTI, delirium, electrolyte imbalance
- Environmental changes - in residents, staff, abusive behaviour from staff or residents, changes in routines, changes in activity
- Psychological factors - comorbid depression, psychosis, disinhibition (mania)
Education of staff about behaviour
Audience analysis
Analysis of baseline knowledge of staff
Pre-educational survey asking what staff want to know
Interactive talk with opportunity to ask questions
Case studies
Practical info and provide other reading resources
Content:
-nature of dementia, types of dementia, explaining it is not patient’s fault
-specific sx of each type of dementia eg. AD - memory, forgetfulness, difficulty dressing, vascular - related to stroke, stepwise deterioration, LBD - VHS
Causes of behavioural disturbances -medical, environmental, psychiatric
Explanation about carrying out behavioural analysis
-ABC and a chart to document
Treatment of behavioural disturbance
-environmental strategies: routine, exercise, music, adequate space
-psychological strategies - calm talking, regular staff, consistent person, family involvement, positive reinforcement. Sleep, avoiding stimulant use
-medication - last resort, risk of antipsychotics and vascular events, small doses in severe agitation (anticholinergic SES, BZD-falls)
Possible causes of cognitive
-Delirium: UTI, chest infection
-Hyponatremia due to SIADH - on antidepressant, lithium
-Does pt have arrhythmia - can lead to PE or stroke and delirium
-Is the pt on L-dopa - can lead to mood changes (excess dopamine resulting in confusion, irritability)
-Toxicity of lithium can occur due to forgetfulness and accidental overdose OR abrupt cessation leading to rebound confusion
-Serotonin syndrome due to fluoxetine and lithium -> confusion, unsteadiness
-Abrupt cessation of SSRI: withdrawal, dizziness, unsteadiness
-LBD - parkinsonism w fluctuating cognition, persistent vivid VHs
-alcohol withdrawal/intoxication
Capacity for Enduring Power of Attorney
To make decisions when they no longer have capacity to make their own decisions about financial affairs
Do they understand what EPA will involve
Do they know they can appoint more than one person
That they will begin and continue making decisions when lacks capacity
The attorney can make legally binding decisions in the POA document
They can cancel POA or change in future if capacity, cannot revoke if lacking capacity
Freedom from influence
Neuroimaging findings in dementia
Alzheimer’s - Structural (CT/MRI)
Ct: generalised cerebral atrophy and ventricular enlargement
Mri: medial temporal lobe atrophy, periventricular white matter lesions
SPECT (functional): tempero-parietal hypoperfusion
Vascular
Structural: infarct, extensive white matter lesions
Functional: patchy multi-focal pattern of hypoperfusion
LBD
Structural: Generalised ventricular enlargement
Spect: Reduced D2 receptor density and dopamine transporter
FT dementia
Structural: Frontal lobe atrophy
SPECT: Anterior perfusion deficits
DSM for Alzheimers
- Memory impairment manifested by impaired ability to learn new information
(anterograde amnesia) or to recall previously learnt information (retrograde amnesia) - Aphasia
- Apraxia - difficulty w skilled movements
- Agnosia - identify objects or people
- Disturbance in executive functioning (planning, organizing, sequencing, abstracting)
RFs for Alzheimers
- Age
- Family history- 1 in 5 and 1 in 6 persons who are relatives of patients with
Alzheimer’s disease will develop the disease - Down syndrome
- ApoE 4- the E4E4 genotype is associated with much higher risk of AD compared
with E3E3 genotype. The E3 allele is less common in Orientals than in Caucasians,
which might account for lower incidence of Alzheimer’s in Orientals - Age of onset before age of 60–65
- AD inheritance for 5% cases
- Three genes account for 30–50% of familial Alzheimer’s disease
Sx of FTD
- Males>females
- Age 45–65
- Positive family history in 50% of patients
- Association between fronto-temporal dementia and motor neuron disease
Behavioural features
* Personality change – apathy, disinhibition e. G. Sexual
* Mental rigidity and inflexibility
* Perseverative and stereotyped behaviour e. G. Collecting items
* overeating
With FTD,unusual or antisocial behavior as well as loss of speech or languageare usually the first symptoms. In later stages, patients develop movement disorders such as unsteadiness, rigidity, slowness, twitches, muscle weakness or difficulty swallowing.
The above features are also present in sub-cortical dementias – e.g. HIV, Parkinson’s disease, Huntington’s disease.
Sx of LBD
- Fluctuating cognition with pronounced variation in alertness and attention
- Recurrent visual hallucinations that are well formed and detailed
- Spontaneous features of parkinsonism
Supportive features - REM sleep behaviour disorder
- Severe neuroleptic sensitivity
- Low dopamine transporter uptake in basal ganglia demonstrated by SPECT or PET
imaging - Falls and syncopal episodes in about 1 in 3 patients
Principles Mx BPSD
GENERAL PRINCIPLES
* Exclude physical cause
* Behavioural management first
* Maintain consistency
* Preserve dignity
* Encourage normal behaviour
* Avoid punishment
Physical environment
* Familiar constant and stress free
* Careful design and good staffing
* Buildings for people should
Make sense, help them find their way
Provide a therapeutic environment
Provide a safe environment
Provide good facilities for staff
Sensory functions
* Evaluate vision and hearing
* Avoid abstract/noisy designs
* Avoid mirrors as can be confusing
* Use soft lighting and calm colours
* Use carpets to absorb sound
* Music
Behavioural interventions
* Identifying target symptoms
* Behavioural analysis based on analysis of antecedents, behaviours and consequences
* Set realistic goals
* Intervention
* Monitor response, e.g. Cohen-Mansfield agitation inventory
* Use reinforcement to maintain desirable behaviour
* Ensure safety throughout the process
* Avoid punishment and preserve dignity
Management of carer’s burden
* Carers assessment –aiming to identify burden, specific problems, fears and worries
* Assess additional support, coping styles, finances
* Address cultural issues and maintain cultural and ethnic sensitivity
* Psychoeducation – inform diagnosis, education about BPSD, and services and
benefits that are available
* Support and advice; doctor, advocacy, carer groups
* Referral to psychologist for counselling, stress management, improve coping skills
* Liaison with psychogeriatric services and GP to provide timely care
* Other community services; meals on wheels, incontinence nurses, aids, adaptation and
safety, home help and supervision
* Placement issues; respite care, day care, low- and high-level nursing homes
* Legal issues; guardianship, power of attorney, advance directives
Pharmacology in BPSD
- Use only after behavioural interventions have been trialled
- 3T approach
Target symptoms e.g. sleep
Titrate from a low staring dose
Time-limit prescriptions - Antipsychotics
- Low dose olanzapine or risperidone
- RANZCP position statement recommends oral risperidone as opposed to olanzapine
- All antipsychotics increase the risk of stroke in dementia
- Antipsychotics decrease quality of life and increase mortality and morbidity
- Donepezil, Galantamine and Rivastigmine are all effective in reducing behavioural
disturbance in dementia - Use BZD’s with caution as can increase risk of falls
Pharmacology in dementia
- Acetylcholinesterase inhibitors (AChE)- (NICE Guidelines)
- Donepezil, rivastigmine, galantamine
- Donepezil and galantamine are selective inhibitors of AChE
- Rivastigmine acts on both AChE and butyrylcholinesterase (BuChE)
- Galantamine also affects nicotinic receptors
- Donepezil can be given once daily but Rivastigmine and Galantamine must be given
twice daily - Recommended in mild to moderate dementia
- Carer’s view of the condition at baseline and follow up should be sought
- Patients who continue on the drug should be reviewed every 6 months by MMSE
score and global, behavioural and functional assessment - Continue only if improvement noted
- Carers view should be sought before cessation
- Adverse effects- nausea, vomiting, insomnia and diarrhoea
- Doses- Donepezil- 5-10mg/day
Rivastigmine- start at 1. 5mgB.D to max 6mg B.D
Galantamine- 12 mg B.D
Old age losses and fears
Losses
-independence of autonomy
-friends and family
-job and social role
-health and mobility
-financial status
fears
-dependency
-disability
-deformity
-death
