W02 - PSYCH: Learning Disability; Old Age Psychiatry; Controversies Flashcards
To be able to discuss the aetiology of learning disabilities.
- single gene: fragileX,PKU, Retts Syndrome
*microdeletion/duplicaation: digeorge, praader-willi, angelman syndrome
- chromosomal abn: downs, sex chromosome abn.
Acquired:
- infective: rubella, zika
- traumatic
- toxic: foetal alcohol syndrome
Idiopathic, but associated with:
- cerebral palsy
- ASD
- epilepsy
Be familiar with the relationship between learning disability and other forms of mental disorder
- higher incidence of psychiatric disorders in those with LD
- more severe
- different presentation in moderate-profound LD
- difficulties in communicating “internal world”
Consider the health inequalities of those with a learning disability.
6 out of 10 lower life expectancy
- respiraatory disease
- cardio disease
- cancers
at risk: deprivation, accessibility, discrimination, minimal evidence
- social exclusion associated with poorer health outcomes, unable to engage socially or be independent
- reaching out to GP etc
Outline the importance of communication skills and aids to enable assessment and management
- non-verbal cues
- alternative communication: symbols, sign, cards
- jargon-free
- require to build up rapport and trust
- Makaton
Makaton is a language programme that uses signs, symbols and speech; giving a person different options when communicating - PECS (Picture Exchange communication system)
Implications for Physical Health in Learning Disabilities
- epilepsy
- sensory impairments
- obesity: predisposes
- GI
Implications for Mental Health in Learning Disabilities
- psychosis, mood disorders, anxiety disorders, dementia, ADHD
Learning disability criteria
intellectual impairment = IQ <70
social dysfunction: impairments in 2+ adaptive skills
onset in developmental period: before age 18
Wolfram Syndrome
DIABETES2 = insipidus, and mellitus
OPTIC N. ATROPHY
BIPOLAR AFFECTIVE DISORDER
DEAFNESS
- present prior to 15yo
> tx for DM and DI
anticonvulsants for muscle twitching
Mild Learning Disability
IQ: 50-69, cognitive age: 9 to under 12yrs
*complex tasks are more difficult: forward planning, problem solving, memorising
*more time to think
* concrete information
* repetition to learn
Moderate learning disability
IQ: 35-49, cognitive age: 6 to under 9yrs
*pronounced executive dysfunction
* language, speech, written comms struggle
* struggle with generalising skills and rules
*require routine and structure
Severe Learning Disability
IQ: 20-34, cognitive age: 3 to under 6yrs
- basic language only, simple repetitive tasks only
- will require support, and using environment to try understand situations
Profound Learning Disability
IQ: <20, cognitive age: below 3yrs
- complex care needs, additional health needs, other disabilities
- unlikely to understand language, communicate through noises and facial. expression
Outline demographic changes in the UK
- getting older
*
Cite the basic epidemiology of psychiatric disorders in old age
- In the community
- In the general hospita
- within the hospital, often 2/3 of admitted elderyl will have a mental disorder:
- depression
- dementia
- delirium
- dementia and delirium = have poorest outcomes and prognosis
Characterise some of the attitudes to ageing
a
Define a dementia syndrome
A for Activities of Daily Living (ADLs)
B for Behavioural and Psychiatric Symptoms of
Dementia (BPSD)
C for Cognitive Impairment
D for Decline
*6 months duration, usually progressive
*PMH clues: Anti-cholnergics,
- Tests: neuropsychology, brain image (CT, MRI), examination
To Dx:
- DYSMNESIA
+ dysphasia (comms)
+ dyspraxia
+ dysgnosia
+ dysexecutive functioning (initiation, inhibition, set-shifting, abstraction)
- functional impacts
Know the commonest types of dementia
Alzheimer’s dementia – 62%
* Early impairment of memory and executive function
Amyloid plaques & tau tangles
Atrophy following neuron death
Reduction in Acetylcholine
Vascular dementia – 17%
* stepwise
* focal impairments
Mixed Dementia – 10%
Lewy body dementia – 4%
Be able to perform a basic cognitive test
a
Know the common cognitive proformas
- MMSE correlates w/ ability to perform daily activities
- MOCA
- DIAMOND: Lewy Body Dementia
4.
Interpret cognitive testing in the context of the history and collateral history
a
Be able to undertake a basic capacity test
1) Does the patient UNDERSTAND the information?
2) Does the patient RETAIN the information long enough to make a decision?
3) Can the patient COMMUNICATE the decision?
4) Can the patient WEIGH UP the information in order to make a decision?
5) Does the patient BELIEVE the information they are given?
- pt deemed to have capacity unless proven otherwise
- pt should be supported, and is not incapable if decision is eccentric or unwise
- anything done must be in best interest
- pt assessed at their peak time
Capacity
Consent
Compliance
Coercion
Certification
Common sense
Define the common psychiatric disorders in old age
alongside dementia
*depression = suicide risk in elderly: loss, few seeking support and psychiatrist
- anxiety disorders
- mania
- late onset schizophrenia
- alcohol problems
- delirium
Outline the basic management of psychiatric disorders in old age
> AChI = mild/mod AD
donepezil
* delays institutionalisation, improves cog funct.
* GI sfx, muscle sfx, syncope, breathing
Memantine = severe AD (glutamate antagonist)
> Lecanemab, Aducanumab = anti-amyloid Ab
* 1st line for reverse physical changes and slow decline in memory and thinking
> Antipsychotics
risperidone, quetiapine
* only with extreme risk
* spontaneous recovery high rate
* lowest dose for longest duration
> Antideppr.
mirtazapine, sertaline
> Anxiolytics
lorazepam
> Hypnotics
zolpidem, zopiclone
> anticonvulsants
valporate, carbamezapine
Understand the organisation of old age psychiatry services
- third of people with dementia live in care homes
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