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Geriatrics > 1: Delirium > Flashcards

1: Delirium Flashcards

1
Q

Define delirium

A

Acute, transient, reversible state of confusion usually the result of an organic process

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2
Q

What % of inpatients >65 are affected by delirium

A

50%

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3
Q

What is the mnemonic to remember the causes of delirium

A

CHIMPS PHONED

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4
Q

What are the causes of delirium

A 
Constipation 
Hypoxia 
Infection
Metabolic disturbance
Pain 
Sleeplessness
Prescription medications 
Hypothermia 
Organ dysfunction (renal/liver)
Nutrition 
Environment 
Drugs and alcohol
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5
Q

What 3 prescription medications can commonly cause delirium

A

Tricyclic antidepressants
Anticholinergic drugs
Benzodiazepines

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6
Q

If a patient presents to inpatient care with what 4 factors are they at an increased risk of delirium

A
  1. > 65y
  2. severe illness
  3. hip fracture
    4.
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7
Q

How do individuals with delirium present

A

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

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8
Q

When are symptoms worse in delirium

A

in the evenings

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9
Q

What are the 3 types of delirium presentations

A

hyperactive
hypoactive
mixed

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10
Q

How does hyperactive delirium present

A 
agitation
restlessness
hallucinations
delusions
aggression 
mood liability
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11
Q

How does hypoactive delirium present

A

excessive sleep
withdrawn
lethargy
inattention

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12
Q

How will a mixed delirium present

A

with symptoms of hyperactive or hypoactive delirium

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13
Q

What test do NICE recommend to confirm delirium

A

Confusion Assessment Method (CAM)

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14
Q

If post-surgery or in critical care what tool is used to diagnose delirium

A

CAM-ICU

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15
Q

What are the 4 features of CAM

A
  1. Acute onset + fluctuating course
  2. Inattention
  3. Disorganised thinking
  4. Reduced level of consciousness
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16
Q

What test is commonly used in practice to identify delirium

A

4-AT

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17
Q

What are the four elements of the 4-AT

A
  1. Alertness
  2. AMT4
  3. Attention
  4. Acute or fluctuating course
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18
Q

What is AMT4

A

Age
D.O.B
Year
Place

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19
Q

What type of history should also be performed in individuals with delirium

A

collateral Hx

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20
Q

What will be ordered for individuals with delirium

A

Confusion Screen

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21
Q

What may a confusion screen include

A
  • Obs
  • Medication Review
- Bloods:
  FBC 
  U+E
  LFT
  TFT 
  INR 
  Calcium 
  Glucose 
  Blood Culture 
  Urinalysis and Urine MC+S 
  CXR - if clinically indicated
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22
Q

Why is an FBC ordered in delirium

A 
WBC - indicate infection 
Macrocytic anaemia (B12 deficiency)
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23
Q

Why are U+Es ordered in delirium

A

Urea - cause encephaloapthy + confusion

Hypernatraemia - associated with confusion

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24
Q

Why are TFTs ordered in delirium

A

Hypo + Hyper thyroidism can present with confusion

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25
Q

Why is a serum calcium profile ordered in delirium

A

Hypercalcaemia can present with confusion

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26
Q

Why is glucose ordered in delirium

A

Hypoglycaemia may cause confusion

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27
Q

How should delirium be managed

A
  1. Maintain effective communication with the patient

2. Treat underlying cause

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28
Q

What is first-line if a individual with delirium appears distressed

A
  1. Verbal and non-verbal de-escalation techniques
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29
Q

If an individual with delirium is at risk to themselves or others, what should be given

A

Short course (<1W) haloperidol (0.5-2mg) PO

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30
Q

If patients will not take haloperidol PO, how should it be taken

A

IM

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31
Q

What is a contraindication to haloperidol use

A

Lewy body dementia

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32
Q

Define dementia

A

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

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33
Q

What is the most common cause of dementia

A

Alzheimer’s disease

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34
Q

What % of dementia is caused by AD

A

34%

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35
Q

What are the 5 types of dementia

A
  1. AD
  2. Vascular dementia
  3. FTD
  4. Lewy body dementia
  5. Parkinsonian dementia
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36
Q

What % of dementia is vascular dementia

A

18%

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37
Q

What % of dementia is FTD

A

12%

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38
Q

What % of dementia is Lewy Body dementia

A

7%

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39
Q

Name 5 reversible causes of dementia

A 
B12 or Folate deficiency 
Medications
Hypothyroidism 
Neurosyphillis
Normal pressure hydrocephalus 
Depression
Subdural haematoma
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40
Q

Name 5 irreversible causes of dementia

A

AD, VD, FTD, Lewy body
progressive multifocal leucoencapholpathy
HIV dementia
CJD

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41
Q

What are the aggravators of dementia

A 
Drugs 
Emotional illness 
Medications 
Eye and ear problems 
Nutritional disorders
Tumour + trauma 
Infection 
Anaemia
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42
Q

What is the course of AD

A

gradual progressive decline over 8-10 years

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43
Q

What are 2 distinctive features to AD

A
  1. loss of episodic memory

2. language impairment

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44
Q

In what order do language features deteriorate

A
  1. Naming
  2. Comprehension
  3. Fluency
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45
Q

How does vascular dementia progress

A

Often an abrupt onset followed by a step-wise progression

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46
Q

What is a distinctive feature of VD

A

often asymmetrical unilateral onset of symptoms (eg. hemiparesis)

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47
Q

What is the course of lewy body dementia

A

steady decline over 8-10y, but can have a more rapid progression

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48
Q

What are 3 distinctive clinical features of lewy body dementia

A
  1. Visual hallucinations
  2. Parkinsonism
  3. Impaired attention
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49
Q

In what age group does fronto-temporal dementia manifest

A

40-69

50
Q

What are 2 distinctive clinical features to FTD

A
  1. Change in personality

2. Apathy

51
Q

What is pseudodementia

A

Often cognitive impairment may present in individuals suffering from dementia. Distinctive feature is that patients often remember the onset

52
Q

What do the majority of patients with alzheimer’s disease also have

A

Vascular Dementia

53
Q

What are 5 genes associated with alzheimer’s disease

A
  1. APP
  2. Presinilin 1
  3. Presinilin 2
  4. Apo E2
  5. Apo E4
54
Q

What does mutations in APP cause

A

early-onset AD

55
Q

On what chromosome is APP located

A

21

56
Q

Why is there though to be an increased risk of alzheimer’s disease in downs syndrome

A

Down syndrome is trisomy 21 - altered APP gene leading to early-onset AD

57
Q

What % of individuals with familial AD have mutations in presinilin 1

A

50%

58
Q

What is the relationship between ApoE2 and AD

A

ApoE2 is protective for AD

59
Q

What is the greatest risk factor for AD

A

Increasing age

60
Q

Name 5 risk factors for AD

A
  • family history
  • CVD
  • dyslipidaemia
  • downs syndrome
  • HTN
  • TBI
61
Q

What is the clinical course of alzheimer’s disease

A

gradual decline in cognition over a period of 8-10y

62
Q

What are 5 symptoms of early stage AD

A
  • Impaired concentration
  • Mild forgetfulness
  • Inability to learn new material
  • Poor performance at work
  • Change in personality
63
Q

What are intermediate symptoms of AD

A
  • Denial
  • Visuospatial defect
  • Progressive memory
    impairment
64
Q

What are 4 late symptoms of AD

A
  • assistance for ADL
  • difficultly remembering
  • paranoid delusions
  • hallucinations
65
Q

What are 3 symptoms of advanced AD

A
  • dependence on others
  • incontinence
  • patients may forget their own name
66
Q

Where do amyloid B plaques form

A

Outside of neurons

67
Q

Where do neurofibrillary tangles form

A

Inside neurons

68
Q

What is first line Ix for dementia

A

History from the patient

Collateral history

69
Q

What is then done to investigate dementia

A

blood test for reversible cause

70
Q

If AD, what tests are then performed

A

cognitive screening tests

71
Q

What are the 5 cognitive tests are recommended by NICE to look for dementia

A
  1. 10 point cognitive screener
  2. 6 item cognitive impairment test
  3. 6 item screener
  4. memory impairment screen
  5. mini cog
  6. test your memory
72
Q

What test do NICE not recommend

A

MMSE

73
Q

What score on the MMSE suggests dementia

A

24/30

74
Q

What test recommended by NICE is unique to AD

A

Verbal episodic memory test

75
Q

If the diagnosis is uncertain on cognitive testing, but AD suspected what should be done

A

FGD-PET

perfusion SPECT

76
Q

What are the 2 non pharmacological treatments for AD

A
  1. group cognitive stimulation therapy

2. group reminisce therapy

77
Q

What is fist line to treat AD

A

Acetyl Choline Esterase Inhibitors

78
Q

What are 3 acetylcholinesterase inhibitors

A
  1. Donepezil
  2. Rivastigmine
  3. Galantamine
79
Q

What is second-line to treat AD

A

Memantine

80
Q

When should memantine monotherapy be given

A

Severe AD

Contraindication to AChE

81
Q

What are other medications that may be given in AD

A
  1. Medication to control BP

2. Antipsychotics - if causing themselves stress

82
Q

What is the prognosis of AD

A

Often survive 7y post-diagnosis

83
Q

What is the most common cause of death in AD

A

Infection

84
Q

Define vascular dementia

A

Global cognitive deficit due to either small or large vessel disease

85
Q

What causes vascular dementia

A

prolonged or severe cerebral ischaemia either due to:

  1. large artery occlusion
  2. lacunar stroke
  3. chronic subcortical ischaemia
86
Q

What type of ischaemia does occlusion of a large artery cause

A

Cortical ischaemia

87
Q

What type of ischaemia does a lacunar stroke cause

A

Subcortical ischaemia due to small vessel occlusion

88
Q

What are 4 risk factors for vascular dementia

A
  1. Age
  2. History of stroke
  3. Cardiovascular risk factors
  4. TBI
89
Q

What are 4 cardiovascular risk factors

A
  1. HTN
  2. DM
  3. Dyslipidaemia
  4. Obesity
90
Q

How will microangiopathic vascular dementia present

A

symptoms progress more gradually and slower than macroangiopathic

91
Q

How will microangiopathic VD present

A

subcortical pathology:

  • impaired memory
  • gait abnormalities
  • loss of visuspatial abnormalities
  • confusion
  • apathy
  • mood disorders
92
Q

How will macroangiopathic dementia present

A

sudden onset of symptoms with often a step-wise progression of symptoms

93
Q

How will macroangiopathic VS present

A

cortical dementia

94
Q

What are 5 signs of cortical dementia (A’s)

A 
Amnesia
Apraxia
Aphasia
Agnosia
Acalculia
95
Q

Explain the pathophysiology of vascular dementia

A

VD can be due to lesions of small (microangiopathy) or larger (macroangiopathy) cerebral arteries which share common risk factors but present very differently

96
Q

Explain the pathophysiology of microangiopathic dementia

A

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.

97
Q

What causes macroangiopathic dementia

A

Atherosclerosis

98
Q

Explain the pathophysiology of macroangiopathic dementia

A

Repeated cortical ischaemia events cause progressive damage to neural networks

99
Q

What is a strategic infarct

A

Infarction in a single (important) area may be sufficient to cause the onset of VD

100
Q

Aside from cognitive testing, what investigation may be used for vascular dementia if the diagnosis is uncertain

A

MRI

101
Q

What is the non pharmacological management of vascular dementia

A

Group cognitive stimulation therapy

Reminisce therapy

102
Q

When should acetylcholinesterase inhibitors be given in vascular dementia

A

Only is suspected underlying AD

103
Q

What 3 things should be controlled in VD

A

BP
Weight loss
Diabetes

104
Q

What are parkinson plus syndromes

A

neurodegenerative disease that presents with parkinsonism plus other features

105
Q

In which gender is lewy body dementia more common

A

Male (4:1)

106
Q

how may lewy body dementia present

A

Fluctuating cognition
Detailed visual hallucinations
Parkinsonism develops later

107
Q

What are lewy bodies comprised of

A

a-synuclein

108
Q

Aside from cognitive testing, what investigation may be performed in suspected lewy body dementia

A

SPECT

DaT scan

109
Q

What non pharmacological management is given for lewy body dementia

A

Group reminisce therapy

Group cognitive stimulation therapy

110
Q

What pharmacological management is given for lewy body dementia

A

acetylcholine esterase inhibitors

111
Q

What acetyl choline esterase inhibitors can be used in lewy body dementia

A

rivastigmine + donepezil

112
Q

What is second line management for lewy body dementia

A

memantine

113
Q

What treatment should not be given in patients with lewy body dementia and why

A

anti-psychotics = may cause irreversible parkinsonism

114
Q

What is fronto-temporal dementia

A

heterogenous group of disorders that involves degeneration of the frontal, insular and temporal cortex

115
Q

What age does FTD usually onset

A

40-69

116
Q

How may patients with FTD present clinically

A 
Executive impairment
Behaviour/personality change
Disinhibition
Hyperorality 
Stereotypes behaviour
117
Q

What is different in FTD compared to other types of dementia

A

visuo-spatial awareness and episodic memory are relatively impaired

118
Q

In addition to cognitive screening what investigations may be used it diagnosis in uncertain

A

FDG-PET

SPECT

119
Q

What should NOT be given in FTD

A

Acetylcholinesterase Inhibitors or memantamine

120
Q

What is the triad of symptoms of normal pressure hydrocephalus

A
  1. Dementia + Bradyphenia
  2. Urinary incontinence
  3. Gait abnormalities

Geriatrics (5 decks)

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