1: Delirium Flashcards
Define delirium
Acute, transient, reversible state of confusion usually the result of an organic process
What % of inpatients >65 are affected by delirium
50%
What is the mnemonic to remember the causes of delirium
CHIMPS PHONED
What are the causes of delirium
Constipation Hypoxia Infection Metabolic disturbance Pain Sleeplessness
Prescription medications Hypothermia Organ dysfunction (renal/liver) Nutrition Environment Drugs and alcohol
What 3 prescription medications can commonly cause delirium
Tricyclic antidepressants
Anticholinergic drugs
Benzodiazepines
If a patient presents to inpatient care with what 4 factors are they at an increased risk of delirium
- > 65y
- severe illness
- hip fracture
4.
How do individuals with delirium present
Globally impaired cognition, perception and consciousness that develops over hours to days and is identified by marked memory deficit, disordered or disorientated thought and reversal of the sleep wake cycle
When are symptoms worse in delirium
in the evenings
What are the 3 types of delirium presentations
hyperactive
hypoactive
mixed
How does hyperactive delirium present
agitation restlessness hallucinations delusions aggression mood liability
How does hypoactive delirium present
excessive sleep
withdrawn
lethargy
inattention
How will a mixed delirium present
with symptoms of hyperactive or hypoactive delirium
What test do NICE recommend to confirm delirium
Confusion Assessment Method (CAM)
If post-surgery or in critical care what tool is used to diagnose delirium
CAM-ICU
What are the 4 features of CAM
- Acute onset + fluctuating course
- Inattention
- Disorganised thinking
- Reduced level of consciousness
What test is commonly used in practice to identify delirium
4-AT
What are the four elements of the 4-AT
- Alertness
- AMT4
- Attention
- Acute or fluctuating course
What is AMT4
Age
D.O.B
Year
Place
What type of history should also be performed in individuals with delirium
collateral Hx
What will be ordered for individuals with delirium
Confusion Screen
What may a confusion screen include
- Obs
- Medication Review
- Bloods: FBC U+E LFT TFT INR Calcium Glucose Blood Culture Urinalysis and Urine MC+S CXR - if clinically indicated
Why is an FBC ordered in delirium
WBC - indicate infection Macrocytic anaemia (B12 deficiency)
Why are U+Es ordered in delirium
Urea - cause encephaloapthy + confusion
Hypernatraemia - associated with confusion
Why are TFTs ordered in delirium
Hypo + Hyper thyroidism can present with confusion
Why is a serum calcium profile ordered in delirium
Hypercalcaemia can present with confusion
Why is glucose ordered in delirium
Hypoglycaemia may cause confusion
How should delirium be managed
- Maintain effective communication with the patient
2. Treat underlying cause
What is first-line if a individual with delirium appears distressed
- Verbal and non-verbal de-escalation techniques
If an individual with delirium is at risk to themselves or others, what should be given
Short course (<1W) haloperidol (0.5-2mg) PO
If patients will not take haloperidol PO, how should it be taken
IM
What is a contraindication to haloperidol use
Lewy body dementia
Define dementia
Clinical syndrome of at least 6 months with chronic + progressive decline in two or more domains of cognitive function (eg. memory + language) in the absence of psychiatric illness or delirium responsible for the impairment
What is the most common cause of dementia
Alzheimer’s disease
What % of dementia is caused by AD
34%
What are the 5 types of dementia
- AD
- Vascular dementia
- FTD
- Lewy body dementia
- Parkinsonian dementia
What % of dementia is vascular dementia
18%
What % of dementia is FTD
12%
What % of dementia is Lewy Body dementia
7%
Name 5 reversible causes of dementia
B12 or Folate deficiency Medications Hypothyroidism Neurosyphillis Normal pressure hydrocephalus Depression Subdural haematoma
Name 5 irreversible causes of dementia
AD, VD, FTD, Lewy body
progressive multifocal leucoencapholpathy
HIV dementia
CJD
What are the aggravators of dementia
Drugs Emotional illness Medications Eye and ear problems Nutritional disorders Tumour + trauma Infection Anaemia
What is the course of AD
gradual progressive decline over 8-10 years
What are 2 distinctive features to AD
- loss of episodic memory
2. language impairment
In what order do language features deteriorate
- Naming
- Comprehension
- Fluency
How does vascular dementia progress
Often an abrupt onset followed by a step-wise progression
What is a distinctive feature of VD
often asymmetrical unilateral onset of symptoms (eg. hemiparesis)
What is the course of lewy body dementia
steady decline over 8-10y, but can have a more rapid progression
What are 3 distinctive clinical features of lewy body dementia
- Visual hallucinations
- Parkinsonism
- Impaired attention
In what age group does fronto-temporal dementia manifest
40-69
What are 2 distinctive clinical features to FTD
- Change in personality
2. Apathy
What is pseudodementia
Often cognitive impairment may present in individuals suffering from dementia. Distinctive feature is that patients often remember the onset
What do the majority of patients with alzheimer’s disease also have
Vascular Dementia
What are 5 genes associated with alzheimer’s disease
- APP
- Presinilin 1
- Presinilin 2
- Apo E2
- Apo E4
What does mutations in APP cause
early-onset AD
On what chromosome is APP located
21
Why is there though to be an increased risk of alzheimer’s disease in downs syndrome
Down syndrome is trisomy 21 - altered APP gene leading to early-onset AD
What % of individuals with familial AD have mutations in presinilin 1
50%
What is the relationship between ApoE2 and AD
ApoE2 is protective for AD
What is the greatest risk factor for AD
Increasing age
Name 5 risk factors for AD
- family history
- CVD
- dyslipidaemia
- downs syndrome
- HTN
- TBI
What is the clinical course of alzheimer’s disease
gradual decline in cognition over a period of 8-10y
What are 5 symptoms of early stage AD
- Impaired concentration
- Mild forgetfulness
- Inability to learn new material
- Poor performance at work
- Change in personality
What are intermediate symptoms of AD
- Denial
- Visuospatial defect
- Progressive memory
impairment
What are 4 late symptoms of AD
- assistance for ADL
- difficultly remembering
- paranoid delusions
- hallucinations
What are 3 symptoms of advanced AD
- dependence on others
- incontinence
- patients may forget their own name
Where do amyloid B plaques form
Outside of neurons
Where do neurofibrillary tangles form
Inside neurons
What is first line Ix for dementia
History from the patient
Collateral history
What is then done to investigate dementia
blood test for reversible cause
If AD, what tests are then performed
cognitive screening tests
What are the 5 cognitive tests are recommended by NICE to look for dementia
- 10 point cognitive screener
- 6 item cognitive impairment test
- 6 item screener
- memory impairment screen
- mini cog
- test your memory
What test do NICE not recommend
MMSE
What score on the MMSE suggests dementia
24/30
What test recommended by NICE is unique to AD
Verbal episodic memory test
If the diagnosis is uncertain on cognitive testing, but AD suspected what should be done
FGD-PET
perfusion SPECT
What are the 2 non pharmacological treatments for AD
- group cognitive stimulation therapy
2. group reminisce therapy
What is fist line to treat AD
Acetyl Choline Esterase Inhibitors
What are 3 acetylcholinesterase inhibitors
- Donepezil
- Rivastigmine
- Galantamine
What is second-line to treat AD
Memantine
When should memantine monotherapy be given
Severe AD
Contraindication to AChE
What are other medications that may be given in AD
- Medication to control BP
2. Antipsychotics - if causing themselves stress
What is the prognosis of AD
Often survive 7y post-diagnosis
What is the most common cause of death in AD
Infection
Define vascular dementia
Global cognitive deficit due to either small or large vessel disease
What causes vascular dementia
prolonged or severe cerebral ischaemia either due to:
- large artery occlusion
- lacunar stroke
- chronic subcortical ischaemia
What type of ischaemia does occlusion of a large artery cause
Cortical ischaemia
What type of ischaemia does a lacunar stroke cause
Subcortical ischaemia due to small vessel occlusion
What are 4 risk factors for vascular dementia
- Age
- History of stroke
- Cardiovascular risk factors
- TBI
What are 4 cardiovascular risk factors
- HTN
- DM
- Dyslipidaemia
- Obesity
How will microangiopathic vascular dementia present
symptoms progress more gradually and slower than macroangiopathic
How will microangiopathic VD present
subcortical pathology:
- impaired memory
- gait abnormalities
- loss of visuspatial abnormalities
- confusion
- apathy
- mood disorders
How will macroangiopathic dementia present
sudden onset of symptoms with often a step-wise progression of symptoms
How will macroangiopathic VS present
cortical dementia
What are 5 signs of cortical dementia (A’s)
Amnesia Apraxia Aphasia Agnosia Acalculia
Explain the pathophysiology of vascular dementia
VD can be due to lesions of small (microangiopathy) or larger (macroangiopathy) cerebral arteries which share common risk factors but present very differently
Explain the pathophysiology of microangiopathic dementia
thickening of the vessel intima leads to stenosis, occlusion and even rupture. This results in infarcts of the subcortical white matter causing diffuse white matter lesions.
What causes macroangiopathic dementia
Atherosclerosis
Explain the pathophysiology of macroangiopathic dementia
Repeated cortical ischaemia events cause progressive damage to neural networks
What is a strategic infarct
Infarction in a single (important) area may be sufficient to cause the onset of VD
Aside from cognitive testing, what investigation may be used for vascular dementia if the diagnosis is uncertain
MRI
What is the non pharmacological management of vascular dementia
Group cognitive stimulation therapy
Reminisce therapy
When should acetylcholinesterase inhibitors be given in vascular dementia
Only is suspected underlying AD
What 3 things should be controlled in VD
BP
Weight loss
Diabetes
What are parkinson plus syndromes
neurodegenerative disease that presents with parkinsonism plus other features
In which gender is lewy body dementia more common
Male (4:1)
how may lewy body dementia present
Fluctuating cognition
Detailed visual hallucinations
Parkinsonism develops later
What are lewy bodies comprised of
a-synuclein
Aside from cognitive testing, what investigation may be performed in suspected lewy body dementia
SPECT
DaT scan
What non pharmacological management is given for lewy body dementia
Group reminisce therapy
Group cognitive stimulation therapy
What pharmacological management is given for lewy body dementia
acetylcholine esterase inhibitors
What acetyl choline esterase inhibitors can be used in lewy body dementia
rivastigmine + donepezil
What is second line management for lewy body dementia
memantine
What treatment should not be given in patients with lewy body dementia and why
anti-psychotics = may cause irreversible parkinsonism
What is fronto-temporal dementia
heterogenous group of disorders that involves degeneration of the frontal, insular and temporal cortex
What age does FTD usually onset
40-69
How may patients with FTD present clinically
Executive impairment Behaviour/personality change Disinhibition Hyperorality Stereotypes behaviour
What is different in FTD compared to other types of dementia
visuo-spatial awareness and episodic memory are relatively impaired
In addition to cognitive screening what investigations may be used it diagnosis in uncertain
FDG-PET
SPECT
What should NOT be given in FTD
Acetylcholinesterase Inhibitors or memantamine
What is the triad of symptoms of normal pressure hydrocephalus
- Dementia + Bradyphenia
- Urinary incontinence
- Gait abnormalities
