The most common type of vascular dementia is multi-infarct dementia (MID), which is caused by a series of small strokes, or “mini-strokes,” that often go unnoticed and cause damage to the cortex of the brain—the area associated with learning, memory, and language. These mini-strokes are sometimes referred to as transient ischemic attacks (TIAs), which result in only temporary, partial blockages of blood supply and brief impairments in consciousness or sight. Over time, however, the damage caused to brain tissue interferes with basic cognitive functions and disrupts everyday functioning.

Multi-infarct dementia causes loss of functioning to specific areas of the brain, impairing some neurological and mental functions and not others. When vascular dementia occurs with other types of dementia, such as Alzheimer’s disease, it is known as “mixed dementia.”

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It is understood that longitudinal opportunities to see elderly patients with psychiatric

disorders can and will take place in all adult psychiatric patient settings throughout

the PGY I to V years. However, dedicated geriatric psychiatry training, relevant to

general psychiatry practice, will include two blocks (Block 1 and 2), each of three

months duration (6 months total). Block 1 will focus on knowledge acquisition and

early skill development of all CanMEDS roles, specific to the elderly patient. Block 2

will re-expose the trainee to elderly patients with a focus on consolidation of

knowledge and enhanced skill development of CanMEDS roles. Both blocks will be

supervised by psychiatrists with enhanced knowledge and skills in geriatric

psychiatry. The overall objective of this dedicated geriatric psychiatry experience is

to enable the general psychiatry trainee to acquire

•

specific age-related psychiatric disorders, as relevant to general psychiatry

•

disorders, who have grown old, as relevant to general psychiatry

•

are outside the scope of general psychiatry, and when consultation with a

dedicated geriatric psychiatrist would be appropriate for optimal patient care

2. The trainee will participate in a continuous evaluation process.

3. CanMEDS 2005 provides the basis for the key competencies and enabling

competencies of the specific objectives for geriatric psychiatry content in blocks 1 and 2

of general psychiatry training.

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Questions of confidentiality arise with regard to the recording of information concerning the patient’s health status and access to that information by both the patient and others. Recent issues have concerned matters arising from the advent of HIV, in relation to infected patients and infected healthcare workers and access to information by patients about themselves.

Negligence suits for medical malpractice represent a booming growth area in legal practice. Causes of action can range from harm caused by failure to remove all medical equipment from the site of surgery to actions for wrongful birth following a failed sterilisation. Actions may also arise from the tort of trespass to the person when a doctor does not seek consent prior to treatment.

The criminal law intersects with medical law at a number of points. The first concerns the matter of consent to treatment. Medical law requires a competent patient to consent to medical treatment or the doctor will be guilty of assault and battery. Medical law sets out when consent is not required and when a patient is deemed not competent. The question of consent has been of vital importance when cases concerning forced medical treatment have arisen. The criminal law will also be relevant when a patient dies while in medical care when the question of the medics’ intention has to be determined. This question has arisen in a number of recent difficult cases, in particular the conjoined twins and the decision to separate them even though one would almost certainly die thereafter. Furthermore, medical law intersects with criminal law to carve out immunity for medical conduct such as restraining a patient on mental health grounds or performing a lawful abortion.

Lastly, medical law addresses a number of important ethical questions. These include questions as to the nature, quality and duration of life. These questions have come before the courts recently with regard to euthanasia, reproductive technology and sterilisation of non-competent patients. These same areas have given rise to questions as to quality of life.

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• The elderly are less likely to admit to depressive symptoms spontaneously.
• The elderly depressed patient may present with persistent pain or other physical complaints
• Depression in old age may present with behavioural disturbance, especially in association with dementia.
• Apparent cognitive impairment or mental slowing, so-called “pseudodementia”, may be an indication of a primary depressive illness.
• In the setting of physical disability or illness, depression may be less easily recognised because of overlapping symptoms.

Dementia: People with dementia (loss of cognitive and intellectual ability caused by cerebral disease) frequently present to their primary care doctors with psychiatric symptoms. Common presentations in the doctor’s surgery that may indicate dementia are acute confusion (delirium superimposed on dementia), listlessness, inactivity and loss of interest (superimposed depression), and medical instability or injury (which may indicate poor compliance with treatment regimens). The cognitive impairment of dementia modifies the clinical presentation of other mental disorders so that it can be difficult to tease out specific target symptoms. For example, depression may be masked by cognitive slowing. It is wise to suspect depression in a patient with vascular dementia who becomes irritable or aggressive.

Forty per cent of people with dementia will develop psychotic symptoms during some phase of their illness

Dementia sufferers are more likely to develop delirium.

Delirium: The elderly, and particularly those with pre-existing dementia, are particularly vulnerable in the setting of acute physical illness and polypharmacy. Suspicions should be raised when there is a sudden onset or increase in confusion or when there is a fluctuation in a person’s mental state, especially when there is worsening at night.

Paranoid disorders: Schizophrenia and delusional disorders in old age can be longstanding or of recent onset. An annual incidence of about 17-23 per 100 000 has been reported in community surveys. Isolated elderly people may be psychotic for some time before they come to the attention of medical services. Initial referral may be via police or other community agencies. A typical presentation may involve an elderly person repeatedly asking police or doctor to intervene because they are being harassed in some way.

Anxiety: It is unusual for primary anxiety disorders to develop for the first time in old age. If they develop, general practitioners should be alert to the possibility of underlying depression or occult physical illness such as cardiac or thyroid disease. Like dementia and post-traumatic stress, longstanding but unrecognised anxiety may be revealed by the death of a spouse or the sudden discontinuation of prescribed or non-prescribed medication.

Dementia causes the (usually gradual) loss of mental abilities such as thinking, remembering and reasoning. It is not a disease, but a group of symptoms that may accompany some diseases or conditions affecting the brain. The most common symptoms include loss of memory, confusion, and changes in personality, mood and behaviour.

Dementia usually affects older people and becomes more common with age. About one in 20 people over the age of 65 will develop some degree of dementia. This figure increases to about one in six people over the age of 85. Dementia can develop in younger people, but is less common, affecting about one in 1,400 of those under 65.

Although most of the people who develop dementia are over the age of 60, it’s important to remember that dementia is not a normal part of growing old.

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