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Ministry of Health of Ukraine

Bukovynian State Medical University


“Approved”

on the methodical meeting

of the Department of neurology, psychiatry

and medical psychology nm. S.M.Savenko

“____” ___________ 2009 (Report № __).

Chief of the Department

_______________________

Professor V.M. Pashkovsky


Methodical INSTRUCTION

for 4-th year students of medical faculty №2

(the speciality “medical affair”)

for independent work during preparing to practical class


Theme 12: General description of organic (including symptomatic) psychic disorders. Mental disorders of declining and senile ages


^ MODULE 2. SPECIAL (NOSOLOGY) PSYCHIATRY


Topical module 3. Organic (including symptomatic) psychic disorders. Ecological psychiatry


Сhernivtsi, 2009

  1. Actuality of theme:


About 15 per cent of the population of Western Europe is aged over 65 years, and it is expected that the proportion of elderly peo­ple, particularly those aged over 85, will continue to rise. Since the prevalence of mental disorder and particularly dementia increases with age, there has been a disproportionate increase in the demand for psychiatric care for the elderly, and this trend is likely to con­tinue.

This part of the lecture is about the psychiatric care of the eld­erly. Although psychiatric disorders at this time of life have some special features, they do not differ greatly from the psychiatric dis­orders of younger adults. It is the needs of elderly psychiatric pa­tients or their carers that set them apart from others and so re­quire separate consideration. Before the disorders and needs of the elderly are considered, some information will be given about nor­mal aging.


2. Duration of practical classes - 2 hours.


^ 3. EDUCATIONAL PURPOSE


3.1. To know:


  • the reason of organic (including symptomatic) psychic disorders and mental disorders of declining and senile ages;

  • irreversible psychiatrical disorders with organic brain;

  • clinical picture of organic disoders;

  • types of flowing of organic disoders (asthenical, explosive, euphorically, apatical );

  • clinical picture asthenical types of flowing;

  • clinical picture explosive types of flowing;

  • clinical picture euphorically types of flowing;

  • clinical picture apatical types of flowing;

  • types of dementia;

  • diagnose and differential diagnosis of organic psychic disorders and mental disorders of declining and senile ages;

  • treatment and prophylactic organic psychic disorders and mental disorders of declining and senile ages.


 3.2. A student must be able:

  • to collect anamnesis in patient with organic psychic disorders and mental disorders of declining and senile ages;

  • to diagnose and conduct differential diagnosis of organic psychic disorders;

  • to diagnose and conduct differential diagnosis of mental disorders of declining and senile ages;

  • to use methods of treatment of organic psychic disorders and mental disorders of declining and senile ages;

  • to conduct prophylactic of organic psychic disorders and mental disorders of declining and senile ages.


^ 3.3.To capture practical skills:

  • to diagnose of organic and symptomatic disorders;

  • to conduct prophylactic works;

  • to prescribe a treatment of patients with organic psychic disorders and mental disorders of declining and senile ages.



^ 4. INTERSUBJECT INTEGRATION (base level of preparation).


Names of previous disciplines

Skills are got

1. Anatomy.


2. Physiology.


3. General psychology.



  1. To know an anatomy and topographical anatomy of cerebrum.

  2. To know the basic cork functions of cerebrum. Able to define the type of higher nervous activity.

  3. To know psychology of psychical processes, consciousness and self- consciousness.



5. Advices to students.

5.1. ^ CONTENTS OF THEME.


Psychiatric Disorders in the Elderly

Delirium

Delirium should be remembered that although the central feature, impairment of consciousness, is invariably present in elderly pa­tients, it is not always obvious, particularly when the onset is grad­ual. For this reason delirium (a reversible disorder) may be misdi­agnosed as dementia (an irreversible disorder). Also, when patients with mild dementia develop unrelated physical disease, such as bronchitis, cognitive function may worsen so that the dementia is thought to be more severe than it really is. Although the mental state improves when the cause of delirium is removed, many of the causes of delirium threaten life and mortality is high.

The basic step in management is to discover and treat the un­derlying cause. While this is done, drugs may be needed to con­trol symptoms. The best choice is generally a small dose of an an­tipsychotic drug such as promazine, thioridazine, or haloperidol which relieves symptoms without increasing confusion. Benzodi­azepines also control the acute symptoms but may increase con­fusion. If a hypnotic is needed, chlormethi azoic, or dichloralphena-zone are often used rather than benzodiazepines.

Dementia in the Elderly

This section is concerned with special points about demen­tia in the elderly. There are four groups of dementia in this age group.


  1. Senile dementia of the Alzheimer type (SDAT) (pre-senile de­mentia).

  2. Vascular dementia. As mentioned above it is caused by seri­ous atherosclerosis and/or hypertensive disease.

  3. Mulii-infarct dementia: as the name suggests, this is due to multiple infarcts in the brain resulting from vascular occlusions.

  4. Dementia due to other causes: this group includes dementia resulting from a wide variety of causes, including neoplasms, in­fections, Parkinson's disease, myxoedema, and vitamin deficiency.

^ Alzheimer's Disease

Prevalence. The prevalence of moderate and severe dementia of the Alzheimer type is about 5 per cent of persons aged over 65 years, and 20 per cent of those aged over 80 years. Therefore as life expectancy increases in developing countries, so the number of Alzheimer's patients will increase. About 80 per cent of these demented people live in the community rather than institutions.

Pathology. The brain is shrunken, with widened sulci and en­larged ventricles. There is cell loss, shrinkage of the dendritic tree, proliferation of astrocytes, and increased gliosis. Senile plaques and neurofibrillary tangles occur throughout the cortical and subcorti­cal grey matter. Presenile and senile Alzheimer dementia are be­lieved by some to be the same disorder because both are associat­ed with neuritic plaques and neurofibrillary tangles, and they have similar neuro-chemical abnormalities. Others have suggested that there are two types of Alzheimer's disease.

Clinical Features. Alzheimer's disease is more frequent among women. Doctors are seldom consulted in the early stages of the disorder. Instead, help is requested when deterioration of function has gradually become obvious or after a sudden worsening asso­ciated with an intercurrent physical illness.

Clinical Features of Alzheimer's Disease

1. Poor memory

2. Progressive disorientation

3. Mood change

4. Restless activity

5. Insomnsa

6. Decline in social behaviour

7. Personality change

8. Dysphasia, dyspraxia


The presenting problem is often minor forgetfulness, which may be difficult to distinguish from the effects of normal aging. Disorientation is usually an early sign and may be evident for the first time when the person is in unfamiliar surroundings, for example on holiday. The mood varies; it may be predominantly depressed, euphoric, flattened, or labile. Many patients are rest­less by day and some sleep poorly at night, waking disorientat­ed and distressed. Social behaviour declines and self-care may be neglected, although some patients maintain a good social facade despite severe cognitive impairment. Personality change may oc­cur, often with exaggeration of less favourable traits. In the lat­er stages of the disorder, the above features progress and signs of parietal lobe dysfunction (such as dysphasia or dyspraxia) may occur.

Course. Incidental physical illness may cause a superimposed delirium resulting in a sudden deterioration in cognitive function from which the patient may not recover fully. Death occurs usu­ally within 5-8 years of the first signs of the disease.

^ Multi-Infarct Dementia

Pathology. Multi-infarct dementia (also called arteriosclerotic dementia) is associated with multiple infarcts of varying size caused by thromboembolism from extracranial arteries or arteriosclero­sis in main vessels. The brain is atrophic and the ventricles are di­lated.

Clinical features. Multi-infarct dementia is slightly more common among men than women. It begins usually in the late sixties or seventies, often more suddenly than Alzheimer's disease and sometimes after a cerebrovascular accident. In some cases emo­tional and personality changes are apparent before impairment of memory and intellect. The symptoms are characteristically fluctu­ating and episodes of confusion are common, particularly at night. Fits or episodes indicating cerebral ischaemia occur at some stage in many cases. There may be neurological signs including pseudo­bulbar palsy, rigidity, akinesia, and brisk reflexes. The diagnosis is difficult to make with certainty unless there is a clear history of stroke or neurological localising: signs. Suggestive features are patchy defects of cognitive function, stepwise progression of the condition, and the presence of hypertension and of arteriosclero­sis in peripheral or retinal vessels.

Clinical Features of Mults-Infarct Dementia

1.Stepwise progression

2. Poor memory

3. Episodes of confusion

4. Mood change

5. Personality change

6. Seizures

7. Neurological signs (see text)

In some cases the features are indistinguishable from Alzheim­er's disease.

Course. The course of multi-in-farct dementia is usually a step­wise progression, with periods of deterioration followed by par­tial recovery for a few months. From the time of diagnosis the life­span averages 4-5 years though the variations are wide. About half the patients die from ischaemic heart disease, and others from cerebral infarction or renal complications.

The Differential Diagnosis of Dementia in the Elderly. General aspects of the diagnosis of dementia are discussed in the chapter on organic psychiatry. In the elderly, dementia has to be differen­tiated from delirium, depressive disorder, and paranoid disorder. Delirium is suggested by impaired and fluctuating consciousness, and by perceptual misinterpretations and visual hallucinations. The differentiation of dementia from affective disorders and paranoid states is discussed later in this chapter. It should be remembered that hypothyroidism may be mistaken for dementia.

It is important to look for treatable causes of dementia, even though they are rare. They include deficiency of vitamin B12, neu­rosyphilis, and operable tumours. The assessment should include a thorough search for treatable associated medical conditions as well as specific causes of dementia since the latter can cause a worsen­ing of a demented patient's condition by inducing a mild delirium

Treatment of Physical Disorder. The first step is to treat any treatable physical disorder. If the latter is the primary cause of the dementia, the disorder can be arrested and may be reversed to some extent. If the physical disorder has caused an associated delirium, the mental state may improve considerably with treatment of the physical disorder.

^ Drug Treatment. Restlessness, which can exhaust the carers as well as the patient, may be reduced with promazine. Antipsychotic drugs may he required to control paranoid delusions, and antidepressants may be indicated when depressive symptoms are prominent.

It has been reported that certain drugs are of specific benefit for the dementia of Alzheimer's disease. There have been no conclusive clinical trials and the use of these drugs is not recommended until convincing evidence for their effectiveness is forthcoming.

Tmatment of Dementia.

1.Treat any primary disorder

2. Treat any superimposed delirium

3. involve and support the relatives

4. Arrange practical help in the home

5. Arrange help for carers, e.g. "holiday admissions"

6. Medication for night and day time restlessness

7. If home care fails, arrange residential of hospital care

There is no specific treatment for multi-infarct dementia; blood ressure should be controlled and if carotid artery stenosis is present specialist opinion should be obtained about surgical treatment.

Psychological and Social Treatment. For elderly demented pa~ ents psychological and social treatments are similar to those for ounger patients. Whenever feasible patients should be cared for t home, particularly when family and friends can contribute to neir care. If necessary, help can be provided by a community psychiatric nurse or social worker. Day care may be needed to help patient and family. Inpatient care may be needed to tide over a risis, or to enable the family to have a period of rest or a holi­day. If the patient cannot be managed at home, residential care in n old people's home may be appropriate. In most cases, long-term are in hospital is required only when intensive nursing is needed.


^ 5.2. Theoretic QUESTIONS:

  1. The reason of organic (including symptomatic) psychic disorders and mental disorders of declining and senile ages.

  2. Irreversible psychiatrical disorders with organic brain.

  3. Clinical picture of organic disoders.

  4. Types of flowing of organic disoders (asthenical, explosive, euphorically, apatical ).

  5. Clinical picture asthenical types of flowing.

  6. Clinical picture explosive types of flowing.

  7. Clinical picture euphorically types of flowing.

  8. Clinical picture apatical types of flowing.

  9. Types of dementia.

  10. Diagnose and differential diagnosis of organic psychic disorders and mental disorders of declining and senile ages.

  11. Treatment and prophylactic organic psychic disorders and mental disorders of declining and senile ages.



^ 5.3. Practical tasks on the class:

1. To collect anamnesis, clinical psychopathological examination of patients organic (including symptomatic) psychic disorders and mental disorders of declining and senile ages.

2. Make up plan of examination and treatment of patient with organic (including symptomatic) psychic disorders and mental disorders of declining and senile ages.

3. .Make up of plan. Diagnose and treatment of patient with organic psychic disorders and mental disorders of declining and senile ages.


^ 5.4. Material for self-contrrol.


A. Questions of self-controls:

  1. The reason of organic (including symptomatic) psychic disorders and mental disorders of declining and senile ages.

  2. Irreversible psychiatrical disorders with organic brain.

  3. Clinical picture of organic disoders.

  4. Types of flowing of organic disoders (asthenical, explosive, euphorically, apatical ).

  5. Clinical picture asthenical types of flowing.

  6. Clinical picture explosive types of flowing.

  7. Clinical picture euphorically types of flowing.

  8. Clinical picture apatical types of flowing.

  9. Types of dementia.

  10. Diagnose and differential diagnosis of organic psychic disorders and mental disorders of declining and senile ages.

  11. Treatment and prophylactic organic psychic disorders and mental disorders of declining and senile ages.

B. Tests:

1. The high level of capabilities is named:

A. temperament.

B. character.

C. capability.

D. creation.

*E. talent.

2. A memory disorder in which someone can recall certain information, but they do not know where or how they obtained the information, named:

*A. Retrograde amnesia

B. Gypomnezia.

C. Anterograde amnesia.

D. Traumatic amnesia

E. Lacunar amnesia.

3. A patient actively casts aside ideas about illness and her consequences are possible, estimates the displays of illness as not "serious feelings", that is why renounces an inspection and treatment or limited to "self-treatment". Which type of reacting on illness?

A. Egocentric.

B. Harmonious.

C. Apathetical.

D. Euphoric.

*E. Anosognosia.

4. Purchased organic and global deterioration of intellectual functioning without clouding of consciousness named:

A. Concrete thinking.

B. Abstract thinking.

C. Mental retardation.

*D. Dementia.

E. Pseudodementia.


5. A patient is sure of presence for him of serious illness, constantly concentrated on the sickly feelings, experiencing and continuous talks about illness result in the exaggerated subjective perception of those, that is present and search of pseudo maladies. Desires to treat oneself are combined with disbelief in success. Which type of reacting on illness?

A. Anxiously-depressed.

*B. Hypochondria.

C. Apathetical.

D. Egocentric.

E. Dysphoric.

6. Ability to appreciate nuances of meaning, multidimensional thinking with ability use metaphors and hypotheses appropriately named:

A. Concrete thinking.

*B. Abstract thinking.

C. Mental retardation.

D. Dementia.

E. Volubility.

7. Ability to understand, recall, mobilize, and constructively integrate previous learning in meeting new situations named:

A. Feeling.

B. Perception.

C. Memory.

*D. Intellect.

E. Thought.

8. False belief, based on incorrect experience about external reality, cannot be corrected named:

*A. Delusion.

B. Neologism.

C. Verbigeration.

D. Derailment.

E. Blocking.


9. Literal thinking, limited use of metaphor without understanding of nuances of meaning named:

*A. Concrete thinking.

B. Abstract thinking.

C. Mental retardation.

D. Dementia.

E. Volubility.


10. The inability to recall some memory or memories of the past, beyond ordinary forgetfulness named:

*A. Retrograde amnesia

B. Gypomnezia.

C. Anterograde amnesia.

D. Traumatic amnesia

E. Lacunar amnesia.


11. A psychical process, higher form of creative activity of man through which the most substantial signs of objects and phenomena of the objective world are represented and their intercommunications open up named:

A. Feeling.

B. Perception.

C. Memory.

D. Attention.

*E. Thought.


12. Inborn lack of intellect to a degree in which there is interference with social and vocational performance named:

A. Concrete thinking.

B. Abstract thinking.

*C. Mental retardation.

D. Dementia.

E. Pseudodementia.

C. Situational tasks:

1. A male patient, 37 years old, became too cheerful for no particular rea-son, he has a subjective feeling of high creative abilities, enthusiasm, elation and increased productivity, in spite of manifest disability to concentrate (im­paired attention); his speed of thinking processes is too high. He is uncritical to his state, and finds it normal.

^ Name the syndrome:

A. Manic (non-psychotic) syndrome

B. Syndrome of dysphoria

C. Hypomanic (non-psychotic) syndrome

D. Obsessive syndrome

E. Depersonalization syndrome

2. A male patient 22 years old, complained of the decrease of physical and mental productivity, as well as increased fatigue, weakness, increased need for rest after easy work. He became irritable, impatient and less toler­ate towards people, it is difficult for him to wait even for a short time; he often has headache, sweats easily, feels prickling sensations in the heart re-gion when worries.

^ Name the syndrome:

A. Depressive syndrome

B. Hypochondriac syndrome

C. Asthenic syndrome

D. Paranoia syndrome

E. Obsessive syndrome


3. The patient's mother complains that at night he gets up from bed with open eyes and roams around the room aimlessly with a vacant expression on his face. He walks around the room, opening wardrobes and drawers of the writing table, goes through the things as though looking for something. One day being in this state, he opened the window, got onto the roof and walked near its edge with no signs of fear. All efforts to wake the patient up when he is in such a state are use­less. The patient doesn't remember anything about his night adventures.

^ Name the probable syndrome:

A. Fugue

B. Trance

C. Ambulatory automatism

D. Somnambulism

E. Motor automatism

4. A patient, while making repairs at home, suddenly stood quite still with the painting brush in his hand, then dropped it. This state lasted for a few seconds. After that the patent was rather confused, for some moments he couldn't understand what was happening. He totally forgot the state he was in and the events around him, occurring while he was in that state.

^ Name the syndrome:

A. Obnubilation

B. Trance

C. Fugue

D. Absence (petit mal)

E. Derealisation

5. A male patient 27 years old complained that suddenly and unintention­ally he found himself in a different city. He couldn't understand, how this could happen. During his travel, of which he was completely unaware, he made an impression of a person who was slightly confused and absentmind­ed, absorbed in his thoughts, but his behaviour was more or less normal.

^ Name the probable syndrome:

A. Fugue

B. Trance

C. Clerambault-Kandinsky syndrome

D. Somnambulism

E. Absence (petit mal)

6. At the hospital department the patient suddenly and unconsciously begins to turn round and round, then undresses quickly, throwing his clothes down. This state lasts for approximately one minute, then suddenly ends. The patient does not remember anything he was doing and what was happening during this period.

^ Name the probable syndrome:

A. Fugue

B. Trance

C. Clerambault-Kandinsky syndrome

D. Somnambulism

E. Absence (petit mal)

7. The parents of a 5-year-old child noticed the strange nature of his games. The boy seemed to transform persistently and for long periods of time into different characters, and this was associated with behavioral disorders. For example, pretending to be a dog, the boy asked for a bone, barked and refused to speak with his parents, explaining later, that "dogs don't speak The intelligence level is normal.

^ Name the probable syndrome

A. Overvalued ideas

B. Delusion-like fantasies

C. Delusions of imagination

D. Paranoia syndrome

E. Depersonalisation syndrome

8. Patient of 39 years old, doctor. Constantly something writes and the written hides with application. In a linguistic contact enters reluctantly, suspicious. Told a treating doctor, that opened the method of treatment of AIDS, but «all his developments were stolen by the agents of institute of oncology». Convinces a doctor, that kidnappers «hired three killers, to put to death me».

1. What pathology of thoughtis it?

2. What syndrome?


^ 6. LITERATURE IS RECOMMENDED:

6.1. Basic:

  1. Clinical Psychiatry from Synopsis of Psychiatry by H.I.Kaplan, B.J.Sadock. – New York: Williams @ Wilkins. – 1997.

  2. Psychiatry.Course of lectures. – Odessa:The Odessa State Medical University. – 2005. – 336 p.

  3. Lectures.

  4. Internet resource.

6.2. Additional:

  1. Морозов Т.В., Шумский Н.Г. Введение в клиническую психиатрию. – Н.Новгород: Изд-во НГМА, 1998.

  2. Попов Ю.В., Вид В.Д. Современная клиническая психиатрия. – М., 1997.

  3. Сонник Г.Т. Психіатрія: Підручник / Г.Т.Сонник, О.К.Напрєєнко, А.М.Скрипніков. – К.: Здоров’я, 2006.   



  


Prepared by assistant S.D.Savka



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