Geriatric Psychiatry
What this domain tests
This domain tests dementia subtype recognition, the delirium–dementia–depression triad, behavioural and psychological symptoms of dementia, and capacity and safeguarding issues that arise in older patients.
Core rules and concepts
- Dementia subtypes: Alzheimer disease is commonest; vascular dementia follows a stepwise course with focal signs; dementia with Lewy bodies shows fluctuating cognition, formed visual hallucinations, parkinsonism, REM sleep behaviour disorder and neuroleptic sensitivity; frontotemporal dementia presents with personality change or language loss.
- Delirium versus dementia: delirium is acute, fluctuating, with impaired attention - always look for a cause: infection, constipation, retention, pain, drugs, electrolytes, hypoxia.
- Depression in later life may present as pseudodementia; it is treatable, and ECT is safe and effective in severe cases.
- BPSD: non-pharmacological approaches first - orientation, routine, sensory and social engagement, carer support. Antipsychotics only short term, at low dose, with awareness of increased mortality and cerebrovascular risk; avoid them entirely in suspected Lewy body disease.
- Anticholinergic burden worsens cognition and should be reviewed at every visit.
Worked example
A 78-year-old becomes acutely confused with visual hallucinations on day two after hip surgery. Fluctuation and inattention indicate delirium superimposed on possible dementia; the priority is finding and treating the cause, not starting a cholinesterase inhibitor.
Traps that cost marks
- Diagnosing dementia while the patient is delirious.
- Giving haloperidol to a patient with parkinsonism or suspected DLB.
- Attributing treatable cognitive decline to "normal ageing".