Old Age

Question 1

Behavioural and Psychological Symptoms in Dementia - Assessment

Answer 1

• Start with open questions
• Existing diagnosis? History?
• Onset and progression?
• Trigger/link with anything>
• ABC of behaviours

Differentials

• Organic causes - intake and elimination, pain, new complaints/unwell, recent falls, fevers?
• Psychiatric - changes in mood? irritability? emotional lability? anhedonia? actively responding or talking to himself?
• Medication - any recent changes to medication?
• Environmental - any changes to staff, routine, activities, visitors?

Question 2

Behavioural and Psychological Symptoms in Dementia - Management

Answer 2

• Assess mental state and capacity
• Physical health - examination, bloods, MSU, X-ray, CT
  
  • Correct treatable physical causes e.g. pain or constipation
• Obtain collateral views - family?

Non-pharmacological interventions:

• Sensory aids
• Orientation devices around
• Reminiscent therapy (old T.V./radio shows/environment), validation therapy, art therapy, aromatherapy, pet therapy, music therapy

Pharmacological:

• Small amount of antipsychotics indicated if ageitated, agressive, distressed or reversed sleep-wake cycle
• IM lorazepam suitable for rapid tranq as a single agent
• Consider antiderpressant if indicated
• Consider cognitive enhancer for dementia
• Covert meds have to be care planned as an MDT if patient lacks capacity and in best interests. Regular reviewed and pharmacy need to approve if crushable.

N.B if home cannot meet needs despite non-drug measures or risk great may need admission under MHA

Question 3

Dementia - Explanation

Answer 3

• Dementia = illness of the brain where all mental functions gradually and irreversibly deteriorate. Often begins with memory difficulties before extending to other functions (skills, orientation, speech, personality).
  
  • At times can be associated with deterioration in emotional control, behaviour and motivation.
• Risk increases with age - 6/100 over 65, 20/100 over 80. Doubles every 5 years.
• Most common dementia in Alzheimer’s disease - accounts for 60%
  
  • Vascular 20-30%, LBD 15-20%
• Prognosis variable - average 5-6 years from diagnosis.
  
  • Worse prognosis = male, specific brain parts affected early, rapid onset
• 40-60% benefit from cognitive enhancers - 1/3 improve slightly, 1/3 plateau and 1/3 have no benefit.

Question 4

Wandering History - Dementia (Carer)

Answer 4

• When did this begin?
• How many episodes?
• Getting more frequent?
• Daytime/ night-time?
• Does she go for a walk every day?
• Where does she go? Same place? Doing what?
  
  • Drinking/spending lots of money?
• Who has been bringing her back and at what time?
• Medical history?
• Medications?
• Risks:
  
  • To self - Crossing roads/falls
  • To others - Agression to others/disinhibition
  • From others - Exploitation by others including carers
  • Neglect - not taking medications? Eating and drinking? Exposure?

Question 5

Alzheimer’s - Genetics

Answer 5

• Risk increased by 3 to 3.5 times if first degree relative affected. Overall risk = 1/5-6.
• Tends to be familial in some families particularly if onset < 65
• Following genes known to be associated:
  
  • Apo-lipoprotein gene on chromosome 21 (20% of early-onset AD)
  • Presenilin 1 gene on chromosome 14
  • Presneilin 2 gene on chromosome 1
• Other risk factors - Down’s syndrome, cardiovascular disease, head injury, diabetes, smoking, inactive lifestyle, history of depression, history of cognitive impairment, pesticides.

Question 6

Dementia - History Taking

Answer 6

• Onset of problem, any trigger, progression - gradual or stepwise?
• 5As - memory, skills, disorientation, speech, personality
  
  • Memory
    
    • Misplaces things?
    • Forgets appointments?
    • What about the past?
  • Disorientation:
    
    • Muddled up with day and dates?
    • Gets confused at times?
    • Difficulty recognising people?
  • Speech:
    
    • Difficulties word finding?
    • Able to follow conversations?
• Differential:
  
  • Low in mood before the onset of problems? (pseudementia due to depression)
  • Visual hallucinations? Movement difficulties? Falls? Fluctuating? (suggests LBD)
  • Cardiac risk factors - HTN, diabetes, hypercholesterolaemia, CVD? (suggests vascular)
  • Increased apathy? Impulsivity? Irritability? Insight? - (suggests frontal lobe)
• Impact on functioning?
  
  • What is he having difficulties with?
    
    • Dressing, washing/toilet, walking, shopping, cooking, transport, finances?
• Risk
  
  • Are there concerns about his behaviour?
  • Risk to self:
    
    • Episodes of wandering
    • Falls
    • Accidents due to fire/flooding at home?
  • Risk to others:
    
    • Episodes of aggression?
  • Risk from others:
    
    • Risk of exploitation/abuse by caregivers
• Physical health
• Past psych history
• Medications
• Drugs/ETOH

Question 7

Vascular Dementia - Explanation

Answer 7

• Vascular dementia is a common type of dementia caused by reduced blood flow to the brain.
  
  • Second most common cause after Alzheimers
  • Typically the consequence of a series of minor strokes leading to a deterioration in cognitive function - often stepwise
  • Risk factors are those for stroke in general: smoking, heart disease, hyperlipidaemia, diabetes, alchohol consumption.
• Progressive deterioration as per other dementias - more likely than Alzheimers to cause other psychiatric issues - depression, delusiona, anxiety and emotional instability.

Question 8

Vascular Dementia - Investigation and Management

Answer 8

• Exmaination and bloods including TFTs, lipids, HBA1c, B12
• CT and MRI may show infarcts, lacunes and leukoaraiosis.
• SPECT and PET may show patchy hypoperfusion
• ECG, may consider carotid doppler and echocardiogram
• NICE guidelines do not recommend use of anti-dementia medications for vascular dementia
• Management focused on correcting underlying CVD/risk factors - e.g. hypertension
• Treat depression if present
• Social assessment - housing, meals, carers, power of attorney, respite
• Functional assessment - OT and physio, safety at home and mobility
• Carers education and support - support groups, respite, crossroads.
• Prognosis - worse than AD, average survival 3 years (6 for AD). Worse prognosis with sever dementia, immobility, urinary incontinence.

Question 9

Frontotemporal Dementia

Answer 9

• Group of related dementias that mainly affect the frontal and anterior temporal areas of the brain
  
  • Frontal affects personality, behaviour, motivation
  • Temporal affects language
• 2nd most common under 65s, 7 % of over 65s, mostly onset age 45-65
• Prognosis – very variable 2-20 yrs, average survival 8yrs.

Question 10

Lewy Body Dementia - Explanation

Answer 10

• Third most common cause of late onset dementia
• 15-20% of dementias overall
• More common in men than women
• Characterised by:
  
  • Fluctuating cognition- short term memory less likely to be affected early
  • Falls
  • Visual hallucinations
  • Tremor/stiffness/Parkinsonism
  • Progressive mental decline as per all dementias
  • Also sensitivity to antipsychotics
  • Also associated with depression and delusions
• Prognosis: 5-8 years - similar to AD
• Distinction from Parkinson’s disease dementia in that in LBD cognitive and EPSEs develop concurrently, in PDD cognitive symptoms occur at least 1 year after motor.

Question 11

Lewy Body Dementia - Assessment and Management

Answer 11

• DaTscan able to differentiate LBD from Alzheimer’s
• Management:
  
  • Rivastigmine - not licensed by NICE but evidence for improvements of cognitive sytmptoms, delusions and hallucinations in LBD. Consider if causing significant distress/impairment
  • Try to avoid antipsychotics to manage mild/moderate psychotic symptoms due to sensitivity. If needed Quetiapine can be considered but monitor closely for SEs.
  • For patients with sleep difficulties consider Clonazepam

Question 12

Mini Mental State Examination (MMSE)

Answer 12

• Orientation:
  
  • Year, season, month, date, time
  • Country, town, district, hospital, ward
• Registration:
  
  • I would like you to remember three objects and repeat them to me immediately, then again in 5 minutes:
    
    • Apple, table, penny
• Attention and Calculation:
  
  • Can you spell the word WORLD for me?
  • Could you spell it backwards?
• Recall:
  
  • Please repeat the three words I told you earlier back to me
• Language:
  
  • Please name the objects I point at (pen, watch)
  • Please repeat the phrase: ‘no ifs, ands or buts’
  • Please follow my instructions (three stage command):
    
    • Place the index finger of your right hand on your nose, on your forehead then on your ear
  • Can you please read this sentence and do what it says: write ‘close your eyes’ on a piece of paper.
  • Could you give me a sentence with a subject and a verb
• Copying:
  
  • Draw two intersecting pentagons and then ask patient to copy

Scoring:

24-30 = no cognitive impariment

18-23 = mild cognitive impairment

0-17 = severe cognitive impairment

Question 13

Delerium - Assessment

Answer 13

• Clarify presenting complaint
  
  • Onset and duration?
  • Fluctuating with time of day?
  • Aware of surroundings?
  • More alert or subdued?
• Possible causes:
  
  • Any underlying medical conditions?
  • Seen recently by GP
  • Any new medications
  • Elimination
    
    • Complaints of constipation?
    • Difficulties PU? New odour, pain or increased frequency?
• Comorbid psychiatric symptoms
  
  • Mood over the past 2 weeks?
  • Decreased interest in doing things recently?
  • Changes in appetite or sleep?
  • Responding to things that aren’t there?
  • More suspicious than usual?
• Risk:
  
  • More agitated than usual?
  • Done anything to risk harming himself or others?
  • Wandering?
• Underlying memory issues:
  
  • Prior to onset of confusion how was memory?
    
    • Issues with short term memory? Long term?
  • Word finding difficulties?
  • Not orientated to time?
  • Not recognising people?
• Functioning and ADLs?
  
  • Grooming, dressing and finances?

Question 14

Delerium - Core Features

Answer 14

Timing

• Acute onset (hours to days)
• Fluctuating course

Symptoms:

• Altered and fluctuating conscious level
• Disturbed sleep/wake cycle
• Changes in cognition - attention, comprehension, abstract thinking
• New perceptual disturbances
• Can be agitated or hypoactive
• Disorientation
• Imparied immediate recall and recent memory

Prognosis:

• Lasts from days to weeks (usually 2-3 weeks if cause treated)
• Untreated mortality 10-20%

Question 15

Delerium - Investigation

Answer 15

• Aim is to identify and treat underlying cause
  
  • Many causes - drugs (most common), metabolic, infective, endocrine, neurological, nutritional, eliminational, basically illness/physiological stress
• Investigations:
  
  • FBC, U+Es, LFTs, CRP, TFTs, glucose, thiamine
  • Infection screen - urine dip/MSU, CXR, (blood cultures)
  • (CT head/MRI head)
  • ECG
  • (UDS)

Question 16

Delerium - Management

Answer 16

• Treat any underlying cause
• Hydration, nutrition and elimination
• Rationalise drug chart
• Ensure sensory aids such as spectacles and hearing aids available
• Adequate lighting in day, small nightlight at night
• Quiet, safe nursing environment, ideally side room
• Family photos, clock/calendar to orientate
• Encourage relatives/carers to visit if possible
• Small number of same nursing staff who introduce themselves by name
• Regular follow-up and monitoring of mental state - consider repeat MMSEs

Question 17

Delerium - Management Pharmacological

Answer 17

• If other measures fail or agitated and at risk to self PRN tranquilization appropriate
  
  • Haloperidol (0.5-1mg up to 6mg daily) first line, alternatively Risperidone (1-4mg up to 6mg daily)
    
    • Lorazepam (0.5mg-1mg up to 4mg daily) also possible but can worsen delerium and increase risk of falls so not first choice - unless ETOH withdrawal the cause