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
*
Fitness to Drive & Dementia
Dementia or Organic Brain Syndrome:
notify DVLA at diagnosis
if early dementia license may be yearly
“those with poor short term memory, disorientation or lack of insight should almost certainly not drive”
Reversible Aetiologies & Dementia
Consider reversible
Delirium
Normal pressure hydrocephalus
Subdural haemorrhage
Tumours
Vitamin B12 deficiency
Hypothyroidism
Hypercalcaemia
Alcohol misuse
Neurosyphilis
Drugs
Anticholinergics
Diagnostic Overshadowing
Attribute change in behaviour to LD rather than underlying disease
Different between PoAttorney Vs Guaardianship
With a power of attorney, you choose who you want to act for you. In a guardianship proceeding, the court chooses who will act as guardian.
*Guardianship requires two medical certificates
Define stigma
“is a social construction that devalues people due to a distinguishing characteristic or mark”
*leads to discriminatory practice, originate from exposed ideas and developed in childhood.
* tolerance depends on closeness of interaction
Define methods of reducing stigma
- good medication management
- CBT approach to experienced stigma
- considering own attitudes and awareness
Applying critical thinking to issues considered by popular press
- MH
- depression: placebo and antidepressant overprescription
- ECT
