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25/04/03 05:56
Old Age Psychiatry
Definition
Syndrome due to disease of the brain, usually of chronic or
progressive nature, in which there are multiple disturbances of higher cortical
function. Usually accompanied by changes in emotional control, social behaviour
and motivation. These changes occur in clear consciousness.
Epidemiology
Causes of Dementia
Pathology
- Eosinophilic structures (Lewy bodies) in cytoplasm of cortical cells and
brain stem
- Plagues
- Very few neurofibrillary tangles
Clinically
- dementia with fluctuations (not due to delirium)
- Marked visuospatial problems
- Prominent visual hallucinations (50%)
- mild parkinsonism
- marled neuroleptic sensitivity
Pathology
- atrophy, widened sulci, shrunken gyri
- senile plaques
- extracellular
- swollen neuronal processes
- amyloid
- Neurofibrillary tangles
- intracellular
- PHF (????)
- Tau protein
- neuronal cell loss
- granulovacuolar degeneration
- gliosis, loss of dendrites
- Hirano bodies
- eosinophilic, cigar shaped
- diminished ACh, CAT neurones, GABA, NA, 5-HT
Risk Factors
- Age
- Family History
- Genes on chromosomes 21, 14, 1, 19
- Down's syndrome
- Head injury
- limited education (or does this just reflect less ability to adapt to
degeneration?)
- Multi infarct dementias
- lacunar infarcts
- deep white matter ischaemia (Binswanger's)
Pathology
- Micro infarcts
- cystic necrosis of infarcted areas
- reactive gliosis
- patches of demyelination of white matter
Risk factors
- old age
- family history
- male sex
- geography and race
- hypertension
- smoking
- diabetes
- cardiac arrhythmia
Clinical Features
Early
- Mild memory impairment
- difficulties with ADLs
- personality changes
- mood changes
- speech
- word finding difficulties
Late
- marked memory impairment
- marked decline in ADLs
- Speech
- paraphasias
- nominal dysphasia
- perseverative
- Behaviour
- day/night reversal
- repetitive requests
- labile mood
- aggression
- wandering
- hyperactivity
- sexual disinhibition
Psychiatric symptoms
- delusions
- persecutory ideas
- hallucinations
- misinterpretations
- depressives syndromes
Diagnosis
- Clinical
- history from informant
- physical examination
- mental state exam
- Bloods
- FBC, U&E, ESR, LFT, TFT, glucose, Ca, PO3, B12 and folate,
Treponema
- CXR
- ECG
- Possibly
- EEG
- CT / MRI
- psychometric testing
Management
- Treat medical disorders & causes of disability
- Assess and maximise ADLs
- finances
- early referral to social services
- most live at home
- home alone
- home care worker
- meals on wheels
- day centre
- home with carer
- ADS / age concern advice
- respite
- CPN f behaviour problems
- high prevalence of depression in carers
- Assess dependency and risk
- LA home
- residential
- nursing homes
- NHS care
- Disturbance of consciousness with reduced ability to focus, sustain or
shift attention
- change in cognition not due to pre-exisiting dementia
- development over short period of time usually hours to days
- Condition likely to be due to
- general medical condition
- substance intoxication
- substance withdrawal
- multiple aetiologies
Common Causes
- Infection
- Drugs
- Cardiac - MI or failure
- Respiratory failure
- Electrolyte disturbance
- Endocrine and metabolic - thyroid, hypoglycaemia
- CNS - CVA,
- Nutritional - thiamine deficiency, cachexia
- Malignancy
- Organ failure - renal, hepatic
- Hypothermia
Risk Factors
- age
- illness severity
- dementia
- dehydration
- general frailty
- sensory impairment
- alcohol use
Clinical Presentation
- Hyperactive
- agitation
- hypervigilant
- restlessness
- perceptual disturbances
- delusions
- Hypoactive
- drowsy
- apathetic
- decreased speech and movement
- Mixed / Fluctuating
Management
- Clarify history and assessment of mental state
- Identify and treat underlying cause
- treat symptoms with modest doses of antipsychotics / sedatives
- well lit, quiet room
- Treat sensory deficits
Roth - "well organised system of paranoid delusions with or without
auditory hallucinations in setting of well preserved personality and affective
response"
Grahame - form of schizophrenia attenuated and modified characterised by
prominent paranoid delusions with or without hallucinations
ICD 10 - persistent delusional disorders
Clinical features
- Systematised paranoid delusional state
- elderly single woman, living alone, socially isolated
- substandard housing, low income
- physically robust
- 40% have impaired hearing
- Onset insidious
- Schneiderian first rank symptoms may be present
- 60 % have depressive symptoms
- Life expectancy near normal
- prognosis poor
- neuroleptics moderately effective - but frequent relapse
- premorbid personality often abnormal
- few social contacts
- unmarried
- married late
- separate
- divorced
Pathogenesis
- Inherited predisposition to develop psychosis
- Social isolation may be protective in early life, but disadvantage in old
age
Epidemiology
- 10% of all psych admissions over 60 years
- Female 7:1 male
- 8.7 /100,00 in 65-74 year old
Treatment
- Physical
- treat medical disorders
- attend to sensory impairment
- antipsychotic drugs
- Psychosocial
- engae in day care, services
- mulidisciplianry approach improtant
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