12 - Confusion in the Elderly Flashcards
What are some causes of confusion in elderly patients?
What is the definition of dementia?
- A chronic, progressive syndrome of insidious onset that causes a decline in higher cortical function lead to impairment of memory, intellect and personality
- Early onset is when symptoms are before 65
What are some of the symptoms of dementia in general?
Cognitive symptoms:
- Impaired memory (temporal lobe involvement)
- Impaired orientation (temporal lobe involvement)
- Impaired learning capacity APRAXIA (temporal lobe involvement)
- Impaired judgement (frontal lobe involvement)
Non-cognitive symptoms:
- Behavioural symptoms: agitation, aggression (frontal lobe), wandering, sexual disinhibition (frontal lobe)
- Depression and anxiety
- Insomnia and daytime drowsiness (decreased cortical activity)
- Visual and auditory hallucinations (false perceptions)
- Persecutory delusions (false beliefs)
- Incontinence, dysphagia
What is the main difference between dementia and delirium?
- Delirium has a drop in consciousness level but dementia doesn’t
How do we diagnose dementia in general?
Diagnosis of exclusion - exclude organic causes of cognitive decline. Look for features of progressive cognitive decline with impairment in daily life activities but normal consciouness level
- Hypothyroidism
- Hypercalcaemia
- B12 deficiency
- Normal pressure hydrocephalus
- Delirium
- Can do blood tests to rule these out, MMSE and CT/MRI to show loss of cortical matter
What is the triad of symptoms in normal pressure hydrocephalus?
- Abnormal gait
- Incontinence
- Confusion
What are some of the different types of dementia?
What are the macro and microscopic changes in Alzheimer’s disease?
Macroscopic:
- Global cortical atrophy (not so much occipital)
- Sulcal widening
- Enlargement of the ventricles (lateral and third)
Microscopic:
- Beta amyloid plaques
- Hyperphosphorylated neurofibrillary tau tangles
(these lead to neuronal death, especially of cholinergic, noradrenergic, serotonergic and those expressing somatostatin)
What are the genes associated with Alzheimer’s disease?
Early onset:
- Beta amyloid precursor protein
- Presenilin 1 and 2
Late onset:
- Apolipoprotein E
How does Alzheimer’s disease first present?
- Deterioration in memory as mainly starts in temporal lobe where hippocampus is
- Deterioration in spatial navigation (wandering round streets)
- Difficulty in language and calculation
- All affecting activities of daily living
How do we treat the progression/alleviate the symptoms of Alzheimer’s disease?
- Cholinesterase inhibitors: donepezil, galantamine. (used as amyloid plaques increase amount of AchE)
- Memantine: inhibits NMDA receptors stopping glutamate activity
What is the difference between Lewy Body dementia and Parkinson’s disease?
- If movement disorder before dementia it is Parkinson’s dementia
- If dementia first then Lewy Body dementia
What would we find microscopically with Lewy Body dementia?
- Aggregation of alpha-synuclein protein that form spherical intracytoplasmic inclusions
- Found in the substantia nigra, temporal lobe, frontal lobe and cingulate gyrus
- Can label alpha-synuclein protein with advanced imaging scans
What are the clinical features of Lewy Body dementia?
3 core features:
- Fluctuating cognition and alertness
- Vivid visual hallucinations
- Features of Parkinsonism (shuffling gait and flexed posture) so many repeated falls
What drugs are given to people with Lewy Body dementia and what drugs should not be given to these patients under any circumstances?
- Cholinesterase inhibitors
- NEVER GIVE DOPAMINE ANTAGONISTS (ANTIPSYCHOTICS)
- Can cause neuroleptic malignant syndrome which is a psychiatric emergency
What are some of the symptoms of neuroleptic malignant syndrome?
- Fever
- Encephalopathy
- Vital sign instability (tachycardia, tachypnoea and fluctuating b.p)
- Elevated creatine phosphokinase
- Rigidity (dopamine antagonism)
What is the pathology behind frontotemporal dementia?
- Second most common early onset dementia (peak onset 55-68)
- Atrophy of frontal and temporal lobes but most symptoms due to frontal lobe dysfunction
- Really rare
What are the symptoms of frontotemporal dementia?
Frontal
- Behavioural disinhibition so personality changed
- Inappropriate social behaviour
- Loss of motivation without depression (due to damage of anterior cingulate cortex)
- Repetitive/ritualistic behaviours
- Primitive reflexes, e.g grap and palmomental
- Broca aphasia
Temporal
- Short/long term memory loss
What can be a differential diagnosis that appears the same as frontotemporal dementia?
Stroke (this will be more acute change)
What is the pathophysiology of vascular dementia and what are the risk factors?
- Cognitive impairment by cerebrovascular disease (multiple mini ischaemic or haemorraghic strokes)
- Risks same for any vascular disease:
- Previous stroke/MI
- Hypertension
- Hypercholesterolaemia
- Diabetes
- Smoking
How does vascular dementia present?
- Stepwise cognitive decline with focal neurological features
- No specific treatment just manage their risk factors
What is the pathophysiology of AIDS-Dementia Complex (ADC)?
- Patients with HIV living longer due to medication so more likely to develop AIDS dementia
- Entry of HIV infected macrophages into the brain is thought to lead to indirect damage to neurones
- Insidious onset but once established rapid progression
What are the investigations you should do when you suspect a dementia case?
- Refer to memory clinic and also do tests on image
- All need to be done within six months of recording a new diagnosis of dementia
(all done to rule out other causes)
What is the presentation of AIDS-Dementia complex and how is it treated?
- Psychomotor retardation (slow thoughts and movements, also seen in depression)
- Tremor
- Ataxia
- Dysarthria
- Incontinence
- Cognitive impairment
- GIVE ANTIVIRALS (treating the HIV)
What is the management plan for a newly diagnosed dementia patient?
Use the bio-psycho social model
- Biological:
Acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine, galantamine) for mild to moderate Alzheimers
NMDA antagonists (e.g memantine) to treat agitation
- Psychological:
Few treatments available due to progressive nature but can refer to elderly psychiatrist
- Social: (see next flashcard)
How do we socially manage the diagnosis of dementia for patients and their family?
- Explain the diagnosis sensitively and talk about problems that will arise over the course and how they will manage them
- Give results of any specific investigations e.g scans
- Talk about stopping driving, making a will and getting a power of attorney
- Discuss day care, nursing care and respite care
- Refer them to Personal Independence Payment to help with financial burden (PIP)
What is the definition of delirium?
- Reversible acute confusion state associated with a variety of insults to the brain which may cause neuronal damage and inflammation
- Dementia can predispose to episodes of delirium
- Use confusion assessment method to diagnose
What are the different types of delirium?
Hypoactive: patient is withdrawn, sleepy, quiet and this type is more likely to be missed
Hyperactive: restless agitated, aggressive
Can be mixed
What are some of the features of delirium?
- Mood may fluctuate rapidly
- Persecutory delusions
- Symptoms worse at start and end of the day (cortisol levels)
What are some of the causes of delirium?
E: endocrine like hyper/hypothyroidism and Addisions/Cushings as these cause electrolyte imbalance
I: intracranial so stroke, cerebral abscess, epilepsy
R: Renal failure so electrolyte imbalance
I: infections like pneumonia, UTI, sepsis, meningitis
Nutritional Vitamin Deficiences
M: metabolism so electrolyte imbalance and hypoxia
What are some drugs that can lead to delirium?
- Withdrawal from alcohol, cocaine, coffee, benzodiazepenes
- Anticholinergics
- Opiates
- Antihistamines
- Dopamine agonists
How do you investigate suspected delirium?
- Do same blood tests as dementia to rule out other causes
- Blood cultures
- Urine dip and cultures
- Oxygen sats
- CXR
- CT head
- Review drug history
How do we treat delirium?
- Treat underlying cause
- Rehydrate
- Keep in calm environment as easily agitated
- Haloperidol if required
What is the prognosis with delirium?
How do we assess a patient who is unconscious?
- Check their breathing
- Lie them on their left side
- Do trap squeeze, sternal rub or fingernails pressure test to test GCS by watching their response to pain
