11) Confusion in Elderly Patients Flashcards
What are the 5 causes of Confusion in Elderly Patients ?
1) Delirium
2) Depression
3) Drugs - Morphine, Alcohol, Zopiclone
4) Dementia
5) Metabolic - HypoThyroidism, Hypercalcaemia , B12 Def, Normal Pressure Hydrocephalus
What is Dementia ?
Progressive decline in higher cortical function, leading to impairment of memory, intellect and personality
What is the presentation of dementia ?
1) Memory Deficit - Unable to learn new information and have short term loss
2) Behavioural Changes
3) Physical Changes - Incontinence, difficulty swallowing
4) Language Disorders - Difficulty understanding language
5) Apraxia - Difficulty carrying out motor skills which they have already learnt
What two categories can dementia be classified into ?
Early Onset and Late Onset
> Depends on whether symptoms manifest before 65 YO
What is the pathophysiology of Alzheimer’s
Microscopic
Macroscopic:
> Global Atrophy of brain lobes, typically Frontal, Parietal and Temporal Lobe
> Sulcus Widening
> Dilation of 3rd and 4th Ventricles
Microscopic:
> Senile Amyloid Plaques - derived from proteolytic breakdown from B amyloid precursor protein due to increase Acetylcholinesterase
> Neurofibrillary Tau Tangles
What Genetic Markers can be Observed in Alzheimer’s
> Early Onset
> Late Onset
Early:
> B amyloid precursor protein
> Presenilin 1 and 2
Late:
> increased expression of ApoE gene - this increases permeability of the brain to Amyloid Plaques
How do you treat Alzheimer;s
Acetylcholinesterase Inhibitor
> Donepezil
> Galantamine
> Rivastigmine
Memantine - Inhibits Glutamate action
Treatment depends on severity
- Mild to Severe
Monotherapy and then add
Give Memantine in addition
What is the pathophysiology of Dementia with Lewy Bodies
> Lewy Bodies use up Ach
- Aggregation of a - synuclein protein
Deposited in the Substania Nigra, Temporal Lobe and Frontal Lobe
What is the typical presentation of Dementia with Lewy Body ?
Triad:
1) Fluctuating Cognition with varying attention and cognition
2) Visual Hallucinations
3) Features of Parkinsons
Very similar to parkinson’s with other presentations of dementia such as Memory Loss
How do you treat Dementia with Lewy Body
Acetylcholinesterase Inhibitors
What is the pathophysiology of Frontal - Temporal Dementia ?
Atrophy of Frontal and Temporal Lobe
Peak onset 55-65
What is the Presenting Complaint of FT Dementia?
Dependent on which lobe has been affected > Behaviour > Impaired judgement > Speech impairment > Primitive Reflexes - Grasp Reflex - Palmomental Reflex
What is the Pathophysiology of Vascular Dementia ?
Infarcts of the brain tissue due atherosclerosis
Risk factors:
1) Hypertension
2) Smoking
3) Vascular Disease
4) Diabetes
What is the presenting complaint of Vascular Dementia ?
Step wise Decline in Cognitive Function with Focal Neurological Symptoms
What is the pathophysiology of AIDs Dementia Complex ?
HIV infected macrophage enters the braid and causes indirect damage to neurones
What is the presenting complaint of ADC
> Cognitive Impairment > Psychomotor retardation > Tremor > Ataxia > Dysarthria > Incontinence
What is treatment for ADC ?
Anti virals
What Investigations are carried out for dementia ?
> FBC > UEs > CRP > TFTs > LFTs > B12 and Folate > MMSE > CT / MRI
What common management plan is used for all dementia cases ?
Using Bio Psycho Social Model > Mobility Problems > Daily Living > Ability to learn new skills > Financial problems
Define Delirium
Acute onset of altered mental status and fluctuating course
> If a person has 2 or more on the CAM score they have delirium
1) Acute Change or fluctuating mental status
2) Altered Consciousness
3) Inattention
4) Disorganised thinking
List some causes of Delirium
D - Drug Toxicity => Withdrawal: Alcohol, Cocaine => Anti Cholinergics, Opiates, Anti histamines, Dopamine Agonists E - Endocrine => Hyper/Hypo Thyroidism => Addison's => Cushing's L- Liver Failure I - Intracranial R - Renal Failure I - Infections => Pneumonia, UTIs, Sepsis, Meningitis U - Urinary Retention / Faecal M - Metabolic => Electrolyte imbalance
What is the treatment of Delirium
Treat underlying cause
Dementia vs Delirium
Onset: > Slow Vs Rapid Course > Steady Decline Vs Fluctuant Hallucinations > Rare Vs Present Speech > Slow Vs Slow/ Fast GCS > Normal Vs Reduced Consciousness > Clear Vs Impaired
How can you assess a patient that is unconscious ?`
> Check breathing / Central Pulse > Lie them on their left side > Call for Help > Assessing - Sternal Rub - Trapezius Squeeze - Fingernail pressure test > Assess GCS
