Intellectual Disability & Geriatric Psychiatric Examination

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Psychiatric Interview – Children/Adolescents with Intellectual Disability (ID)

• Goal ⇨ obtain accurate info at patient’s developmental level while respecting chronological age.
• FIRST SCREEN ⇨ observe caretaker–patient communication to estimate receptive/expressive language.
• If gesture/sign-based communication ⇨ caretakers often serve as interpreters.
• Patients with mild ID usually aware of differences → anxiety, shame.
– Give clear, concrete explanation of diagnostic steps.
– Provide age-appropriate praise/support.
• Techniques to keep focus ⇨ subtle direction, structure, positive reinforcement.
• Core developmental domains to explore:
– \text{Frustration tolerance}
– \text{Impulse control}
– \text{Aggressive motor/sexual behaviour}
– \text{Self-image + confidence}
– \text{Tenacity, curiosity, environmental exploration}

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Standardised Cognitive Tests

Age-band & principal tools:
• 6\text{–}16\,\text{yr} ⇨ Wechsler Intelligence Scale for Children (WISC).
• 3\text{–}6\,\text{yr} ⇨ Wechsler Preschool & Primary Scale of Intelligence-Revised (WPPSI-R).
• \ge 2\,\text{yr} ⇨ Stanford–Binet IV (advantage = usable in younger toddlers).
• 2.5\text{–}12.5\,\text{yr} ⇨ Kaufman Assessment Battery for Children (K-ABC).
• 11\text{–}85\,\text{yr} ⇨ Kaufman Adolescent & Adult Intelligence Test.
• All tools assess multiple domains (verbal, performance, memory, problem-solving).

Adaptive Function Scales

• Concept ⇨ “how the child manages everyday life,” varies across settings.
• Vineland Adaptive Behavior Scales (birth – 18\,\text{yr})
– Communication (receptive/expressive/written).
– Daily Living (personal/domestic/community).
– Socialisation (relations/play/coping).
– Motor (fine/gross).

Behavioural Rating Scales

• Aberrant Behavior Checklist (ABC).
• Developmental Behavior Checklist (DBC).
• Behavior Problem Inventory (BPI) ⇨ screens self-injury, aggression, stereotypy.
• Psychopathology Inventory for Mentally Retarded Adults (PIMRA).

Infant/Toddler Screening & Controversy

• Predictive value of infant tests ⇨ mixed; correlation \uparrow with age at testing.
• Quick visual-motor screens: copying figures, Goodenough Draw-a-Person, Kohs Blocks, geometric puzzles.
• Infant tools: Gesell, Bayley, Cattell Infant Intelligence Scale.
• Peabody Vocabulary Test ⇨ common picture-based lexicon assessment.

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Additional Cognitive/Perceptual Tests

• Bender Gestalt & Benton Visual Retention ⇨ visuospatial/visual memory.
• Comprehensive eval must include perceptual, motor, linguistic, cognitive domains.

Physical Examination – Dysmorphic Clues

• Head size/shape ⇨ microcephaly, hydrocephalus, Down syndrome.
• Facial markers ⇨ hypertelorism, flat nasal bridge, epicanthal folds (e.g.0 FAS).
• Eyes/ears/tongue/teeth anomalies may index syndromes.
• Skin/hair texture, high-arched palate, thyroid size, limb-trunk proportions.
• Measure OFC (occipito-frontal circumference).
• Dermatoglyphics ⇨ abnormal palmar ridges/flexion creases in many chromosomal disorders.

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Neurological Examination in ID

• Sensory impairment common:
– Hearing loss in 10\% of ID (≈4\times general pop).
– Visual issues \rightarrow blindness, spatial agnosia, body-image disturbances.
• Seizures in 10\% of ID; \frac13 of severe-ID group.
• Severity of neurological abnormalities \propto degree of ID.
• Motor area disturbance ⇨ spasticity/hypotonia, hyperreflexia, choreoathetosis, clumsiness.

Behavioural Phenotype Table (Selected Syndromes)

Down Syndrome

• Etiology ⇨ Trisomy 21 (nondisjunction 95\%, translocation 4\%).
• Incidence ⇨ \frac1{1000} live births (risk \uparrow with maternal age: 1{:}2500 @<30; 1{:}80 @40; 1{:}32 @45). • Somatic ⇨ hypotonia, up-slanted fissures, simian crease, congenital heart disease, thyroid issues. • Behavior ⇨ passive, sociable, childhood hyperactivity, stubbornness; \text{Verbal} > \text{Auditory-processing}; high depression & early Alzheimer risk (β-amyloid gene 21q21.1).

Fragile X Syndrome

• Gene ⇨ FMR-1 silenced by >200 CGG repeats, locus Xq27.3.
• Incidence 1{:}1000 ♂, 1{:}3000 ♀; accounts for 10\text{–}12\% male ID.
• Somatic ⇨ long face, large ears, macroorchidism, MVP, joint laxity.
• Behavior ⇨ hyperactivity, anxiety, stereotypy, gaze aversion; \text{Verbal IQ} > \text{Performance IQ}; severity milder in females.

Prader–Willi Syndrome

• Etiology ⇨ paternal deletion 15q11\text{–}q13 or maternal uniparental disomy.
• Features ⇨ neonatal hypotonia, failure-to-thrive, later hyperphagia/obesity, small hands/feet, hypogonadism.
• Behavior ⇨ compulsivity, tantrums, daytime sleepiness, borderline–moderate ID.

Angelman Syndrome

• Maternal deletion 15q11\text{–}q13 (GABA-B3).
• Features ⇨ microcephaly, seizures 90\%, ataxia, wide grin.
• Behavior ⇨ “happy puppet” laughter, hand-flap, profound ID, poor sleep.

Cornelia de Lange, Williams, Cri-du-chat, Smith–Magenis, Rubinstein–Taybi, Tuberous Sclerosis, NF1, Lesch–Nyhan, Galactosemia, PKU, Hurler, Hunter, Fetal Alcohol Syndrome

• Each includes distinct chromosomal/enzymatic defect, dysmorphism, and characteristic behavioural phenotype (self-injury, anxiety, sociability, etc.).
• Clinical utility ⇨ recognising phenotype directs genetic testing, anticipatory guidance, tailored behavioural/medical interventions.

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Psychiatric Examination – Older Adults

• Same framework as younger adults but heightened attention to cognitive status & consent capacity.
• Independent collateral history critical when cognition impaired.
• ALWAYS see patient alone at some point ⇨ assess suicidality/paranoia.
• Older population highly heterogeneous (robust 75-yr-old vs frail 96-yr-old).

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Psychiatric History Elements

  1. Identification & chief complaint.

  2. HPI & past psych hx.

  3. Personal/social: childhood, education, coping styles, hobbies, friendships, retirement attitudes, future plans.

  4. Family hx: dementia, depression, alcohol dependence (e.g.0 Alzheimer’s autosomal dominant in 10\text{–}30\% offspring).

  5. Current social support & finances.

  6. Marital/sexual history (must overcome age-bias; sexuality remains salient).

  7. Complete medication review (OTC, herbal).

  8. Age-associated memory complaints often benign ("benign senescent forgetfulness").

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Mental Status Examination – Special Geriatric Points

• Repeat exams may be necessary (fluctuating delirium, variable effort).

General Description

– Observe gait, tremor (e.g.0 Parkinson’s mask-like facies), involuntary oro-buccal movements (TD).
– Hearing aid presence.

Functional Assessment

– Activities of Daily Living (ADLs): toileting, dressing, cooking, grooming, eating.

Mood & Affect

– Suicide leading cause of death; loneliness common trigger.
– Ask direct questions re suicide (life worth living? burden?).
– Frontal lobe lesion ⇨ witzelsucht (pun-making).
– Dominant lobe dysfunction ⇨ dysprosody.

Perceptual Disturbances

– Sensory deprivation hallucinations vs organic psychosis.
– Assess agnosias: anosognosia, atopognosia, prosopagnosia.

Language (Aphasias)

– Broca (non-fluent) ⇨ intact comprehension, poor articulation.
– Wernicke (fluent) ⇨ impaired comprehension, paraphasias.
– Global ⇨ combined deficit.
– Ideomotor apraxia test (demonstrate key/match).

Visuospatial & Thought

– Use figure-copy tasks; decline expected but excess suggests lesion.
– Look for concreteness, neologisms, delusions, etc.

Sensorium & Cognition

– Consciousness level, orientation (time < place < person significance).
– Memory: immediate (digit span 6\rightarrow5), recent (story recall), remote (DOB).
– Identify retrograde vs anterograde deficits; confabulation.
– Intellectual tasks: serial 7s from 100, count back 20\rightarrow1.
– Judgment questions (lost letter, smoke in theatre).

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Neuropsychological & Laboratory Tools

• Mini-Mental State Examination (MMSE)
– Max 30, screens orientation, attention, recall, language, commands.
– Not diagnostic but tracks decline & treatment.
• Wechsler Adult Intelligence Scale-Revised (WAIS-R)
– Verbal vs Performance IQ; performance more sensitive to brain damage & aging.
• Bender Gestalt, Halstead–Reitan ⇨ visuospatial & processing speed.
• Geriatric Depression Scale ⇨ excludes somatic items to avoid confounding.

Medical & Medication Review

• Elderly have more comorbidities & polypharmacy.
• Drugs may cause:
– Depression (e.g.0 β-blockers).
– Cognitive impairment (benzodiazepines).
– Delirium (anticholinergics).
– Seizures (neuroleptics).
• Look for misuse & diet–drug interactions.
• Somatic illness can masquerade as psych disorder (infection, MI, stroke).

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Early Detection & Prevention – Alzheimer Disease (AD)

• AD hallmark ⇨ progressive accumulation of neuritic plaques & neurofibrillary tangles.
• Prevention > repair ⇨ focus on delaying onset.
• Surrogate biomarkers:
– PET, fMRI to detect hypometabolism.
– Genetic risk markers (e.g.0 \varepsilon4 APOE).
• Ongoing interventions: cholinesterase inhibitors, statins, NSAIDs, antioxidants (vitamin E).
• Novel plaque/tangle imaging enables evaluation of anti-amyloid therapies.

Practical/Philosophical Implications

• Ethical need for informed consent in cognitively impaired both pediatrics & geriatrics.
• Genetic counselling fundamental when behavioural phenotype suggests hereditary syndrome (e.g.0 Fragile X).
• Early detection research balances hope with respect for autonomy & potential stigma.

These notes synthesise the entire transcript, page-by-page, outlining clinical techniques, diagnostic tools, syndrome phenotypes, and special considerations across life-span psychiatry.