W5 old age, forensics

Question 1

how does unconscious bias affect old people with depression and IAPT referrals

Answer 1

1/6 old people treated for depression
1/2 young people are referred for MH, only 6% old are

older dec referral to IAPT but better compliance and recovery rates

Question 2

whats the most common mental disorders in eldelry

Answer 2

depression - most common
dementia
delirium

Question 3

what do you include in risk assessment for older adult

Answer 3

suicide and self harm

impaired cognition - cooking, wandering, financial abuse, driving, pets

physical health - non-complicance, falls, poor oral intake and self care

vulnerability - relatives who reappear, scams, carers, internet

Question 4

what is the SQUID single question in delirium

Answer 4

is this patient more confused or drowsy than usual

Question 5

what condition can cause pathologlogical crying

Answer 5

stroke

Question 6

what are charles bonnet visual hallucinations

Answer 6

well formed, vivid elaborate hallucinations - in blind person, know theyre hallucinating

Question 7

what forms the dementia screen (investigations)

Answer 7

BLOODS

• FBC
• U&E
• LFTS
• Vit D
• Ca/Mg/Phos
• CRP
• B12, folate
• TFTS
• coags
• lipids
• HBA1c
• Hep B/C/HIV/ syphilis serology

depend on clinical presentation - MSU, CXR, ECG

Question 8

epidemiology of depression in OA

Answer 8

• MC MH prob
• 22% men, 28% W >65
• 40% OA in care homes
• inc somatic and hypochondriacial worriers
• agitated depression
• pseudodementia
• link with vascular disease

Question 9

what are important symptoms to ask about depression in OA

Answer 9

biological - less useful bc lots of changes in OA

cognition - v useful
–> owrthlessness, guilt, hopelessness, anhedonia

GDS geriatric depression scale
frailty

Question 10

what does the graduates mean in oa

Answer 10

chronic schizophrenia, bipolar

Question 11

functional and organic differentials for psychosis in OA

Answer 11

functional

• schizophrenia
• affective disorders (BPAD, schizoaffective, depression with psychotic features)
• delusional disorders (delusional jealously)

organic

• delirium
• dementia (also delusional jealousy)

Question 12

what is paraphrenia

Answer 12

LOS late onset schizophrenia

VLOSLP = very late onset scizophrenia like pyschosis = paraphrenia

Question 13

3 international consensus classification for schizophrenia in OA

Answer 13

chronic schizophrenia (graduates)
late onset schixophrenia (>40)
very late onset schizophrenia like pyschosis (>60)

Question 14

ICD 10 for schizophrenia in OA

Answer 14

late paraphrenia = not own classification

• -> 3 categories
  1) schizophrenia ( no age limit)

2) delusion disorder - not if persistant AH
3) other persistent delusional disorders - with AH

present for most of the tme during an episode for at least 1 month

Question 15

ICD-10 criteria for schixophrenia

Answer 15

present for most of the time during an episode which lasts > 1 months

at least 1:
- thought echo/ insetionwithdrawal/ broadcasting

• delusions: content, influence, passivity, sensations
• hallucinations: running commentary, 3rd person
• persistent delusions of other kinds that are culturally inappropriate and completely impossible

Question 16

what is the clinical picture of LOS and VLOSLP?

Answer 16

MC - delusions –> persecution, reference, misidentification (someone changed person), partition (neighbours walk through walls and steal their stuff)

non-verbal AH
3rd person AH
hallucinations
FTD, negative symptoms rare

Question 17

VLOSLP risk factors

Answer 17

Wx4 >Men

men bimodal age - 21 and 39
female - 22, 37 and 62

age-assoc psychosocial fx - retired, financial probs, bereavment,
genetics - less than young onset

premorbid schizoid and paranoid assoc, social isolation assoc

Question 18

why do OA develop schizophrenia

Answer 18

females - lose more brain volume in parietal lobes?, xc dopamine?

Question 19

2 hypothesis for schizophrenia in OA

Answer 19

hypothesis 1 = genetic susceptibility
- neuronal loss due to aging/ vascular changes

2 - no genetic risk, single event (vascular) precipitates

Question 20

what are the diff types of antipsychotics useful for in OA schizophrenia

Answer 20

typical - better at treating ++ symptoms, higher risk SEs

atypical - better tolerated and treating — symptoms

Question 21

key potential side effects of antipsychotics

Answer 21

EPSE = parkinsonism, akathesia, acute dystonia, tardive dyskinesia

anticholinergic = urinary hesitance, constiPation, blurred vision, dry mouth, delirium

other = postural hypotension, sedation so fall, hypersalivations, QTc prolonged, weight gain, DM, epilipesy

start low and go slow

Question 22

what drugs can be used of OA pyshcois

Answer 22

ripseriodone and olanzapine equally effective

quetiapine less so
aripiprazole

clozapine - inc neutropenia

Question 23

how do you treat delusion disorder

Answer 23

poor response if persecutory

olanzapine and risperidone

facilitate treatment adherence, educate, social skills training, minise risk factors

Question 24

what is othello syndrome

Answer 24

degree of jealousy/ belief in infidelity is to delusion intensity
–> gather evidence, stalk, threaten spouse or strangers for the truth

• assoc with organic (post-stroke, dementia, PD) and functional psychoses and alcoholism

Question 25

what are BPSD?

Answer 25

``` repetitive mood disturbance apathy social inappropriatiness agitation wandering psychosis sleep distrubance PTSD ```

Question 26

what does a diagnosis of dementia signify

Answer 26

signif decline in 1 or more cognitive domain documented by neuropsychological testing ``` = complex attention executive function learning and memory language perceptual motor social cogntion ``` --> cognitive deficity not better explained by another mental disorder

Question 27

what is the PIECES approach to BPSD

Answer 27

Physical problem or discomfort Intellectual/ cognitive change emotional capacities = ADL environemnt = privacy, restraint, lighting social/cultural factors = values, life story, trauma

Question 28

meds in Alzheimers and lewy body dementia

Answer 28

consider acetyl choline esterase inhibitor or memantine

Question 29

if think underlying depression in dementia pt, try MEDS?

Answer 29

sertraline

Question 30

id BPSD - agitated, irritable

Answer 30

try trazadone

Question 31

what is the guidance for use of antipsychotics in BPSD

Answer 31

UK -risperidone = only licensed drug for BPSD use only if 1) risk of harm -self or others 2) agitatiion, halllucinations, delusions causing severe distress ! beware in LBD or PD --> worsen motor symptoms, cause severe antipsychotic sensitivity reaction use low dose, reassess every 6 weeks, stop if no benefit

Question 32

what drugs must you avoiud in LBD and PD

Answer 32

antipsychotics --> worsen motor symptoms

Question 33

what drug can use use for BPSD

Answer 33

risperidone - only licensed drug for persistent aggression, unresponsive to non-pharma tx, risk of harm

Question 34

what must you consider before assess capacity

Answer 34

impairment or disturbance of brain/mind

Question 35

DOLs

Answer 35

under continuous supervision and control not free to leave lacks capacity to consent to this

Question 36

what are the forensic sections

Answer 36

35 --> establish dx and fitness to plead, no leave 36 -> treatment, no leave 37 --> hopsital treatment instead of prison 38 --> convicted (not sentenced) hospital for treatment --> then S37 or prison 47 -->transfer of sentenced prisoner to hospital 48 --> prisoner waiting to be sentenced, to hospital --> section 37 or 41 or prison 49 and 41 --> restriction orders. S49 for pts oon S47 and S48. S41 for pts on S37 and commmunity

Question 37

what does diminished responsibility mean

Answer 37

partial defence - can't be found to be entirely responsible for the actions they undertook

Question 38

what is the proportion of all homicides perpetrated by people with schiophrenia?

Answer 38

5%

Question 39

in an 85 YO man with delirium, tremor and regidity, which medications would you avoid? ``` A antipsychotics B antimuscarinics C diazepam D levodopa E lorazepam ```

Answer 39

antipsychotics - worsen PD symptoms | avoid in Lewy body demenita and demntia in PD

Question 40

what's the most common BPSD in Alzheimers

Answer 40

depression - 40%

Question 41

what is the most common psychiatric problem associated with homicides?

Answer 41

drug and alcohol dependence