3 Ds - Delirium, dementia, depression Flashcards
delirium - features
worsening confusion
rapid onset and fluctuant
altered consciousness (alert/aware), disordered thinking
secondary cause
other: emotions, behaviours, hypo/hyperactive, perception changes
hypo 40%, hyper 25%, mixed 35%
delirium - RF/triggers
RF: dementia, frail, age, co-morbidities, sensory impairment
triggers: drugs/substances, infection, surgery, brain disease, hypoxia, metabolic
delirium - assessment approach
history and collateral
exam: obs, sepsis, MSK, neuro, sensory, PR
investigations
delirium - aetiology
‘DELIRIUM’: drugs, electrolytes, lack of drugs, infection, reduced senses, intracranial, urinary retention, myocardial
also: trauma, hypoxia, vascular, toxins/heavy metals, sleep, anx/depp
delirium - prognosis
increased mortality (2x; 1y 40%) longer Ax + institutionalisation ^complications 3x dementia risk (?herald/trigger) reduced function/incomplete recovery
delirium - epidemiology
20% IP prevalence, 1-2% GP; 50% have dementia (5-10x risk); 67% of dementia IP
AMU 10%, post-op 15%, stroke 25%, HCOP 30%, post-op hip 50%, ITU 60%, palliative 80%
often under-recognised and under-Dx: always consider!!
delirium - management
1) ID and treat cause
2) manage Sx: enviro, pain, hydration, nutrition
3) prevent complications: falls, infections, pressure, incontinence, meds, nutrition, fx decline
4) explanations: patient/family
environment: calm, familiar, orientating, big signs
treatment: reassure safety, minimally invasive (no lines), rehydrate, nutrition, bowels, meds, mobility, senses
delirium - DDx
dementia: chronic, general function and IQ
psychiatric: psychosis (e.g. schizophrenia or depression)
depression - epidemiology
commonest mental disorder in elderly
affects 30% community, 15-20% clinically depressed
1 in 6 don’t discuss Sx with GP
1 in 5 GP attendees have psychological symptoms
1 in 20 are likely to respond to ADD
23% of RH, 30-35% of NH, 29% acute med IP, 40-45% post-stroke
85% also have anxiety
25% of suicides are elderly
10-20% have delirium
depression - features
more severe baseline illness,
more likely to have psychosis (incl. paranoia), anxiety, and somatisation
more psychosocial impairment (incl. agitation), sleep issues, appetite/weight
increased risk of chronic illness
poorer, slower treatment response
increased suicide risk
pseudo-dementia and delirium DDx; ‘masked depression’
depression - suicide features
more successful: 1in4 success (vs. 1in15-20)
more commonly felt, less commonly expressed
check risk before prescribing ADD
RF: male, bereaved, alone/isolated, pain/physical illness, alcohol, depressed, GP
depression - management
bio: ADD (SSRIs), comorbidities, med r/v
psycho: education + CBT/IAPT
social: usuals; carer support (e.g. respite), diet and exercise, groups
depression - history
HPC: onset, Sx, triggers/RF, coping mechs
alcohol/substance
risk/insight; SI
depression - RF/triggers
triggers: life events; health; stress; somatisation
risk factors: PMH/FH; poor physical health, or loss of health/mobility; poverty, or institutionalised; widow/er, alone/isolate, poor social support/no confidant; personality; recent loss/bereavement, retirement; some medications
depression - HCE differences
settings: home/OPD/CH/IP memory/MCI: collaterals comorbidities + polypharma (MH risk) perspective: significance and attribution suicide risk high: more successful
white matter hyperintensity, vascular depression
depression - types
mild/moderate/severe +/- psychotic recurrent depressive BAD organic depressive episode mixed anx/depp dysthymia adjustment disorder minor depressive disorder
depression - impact
physical health/neglect
QoL/ADL/function
slower recovery
morbidity and mortality
dementia - definition/diagnosis
“loss of intellectual capacity and personality due to neuron loss/damage, beyond normal ageing”
4 diagnostic criteria:
- 2 higher function impairments (memory essential)
- impaired functioning e.g. ADLs
- no underlying cause (medical or psychiatric) i.e. primary
- duration > 6 months
dementia - stats
prevalence: 17-25m worldwide; 850,000 UK (>1m by 2025; 40% increase in next 15y)
33% >95yo; 20% >80yo; 15,000 are younger (~1in20)
F>M (2x)
64% of care home residents
cost: £26b to NHS yearly; family carers save NHS £6b; more than stroke + cancer + CHD; >1% GDP
£11.6b unpaid care, 4.3 health care, 4.5 state social care, 5.8 private social care; other = 0.1b
60,000 deaths per year;
comorbidity: 70% have CMs; 61% anx/depp, 41% lonely, 52% lacking support, 24% feel isolated, 28% lacking capacity/decisions, 90% house-bound
10% delirium
dementia - genetics
early-onset AD: rare; APP, presenilin 1/2; onset 30-40y; 2x FHX
late-onset AD: apoE4 or apoE3 (more stats)
FTD: MAPP, GRN, TAU
dementia - features
cortical: memory loss; language; social skills; cognition
subcortical: emotions, movements, memory
personality change disorientation loss of higher functions -memory -executive function -visuospatial -attention and agnosia -planning and ADLs - dyspraxia and apraxia -speech - dysphasia
dementia - drugs/medications
AchE: increase ACH, increase NT; may slow progression; donepezil, galantamine, rivastigmine
NMDA: blocks glutamate, reduces toxic overstimulation and degeneration;
antipsychotics: symptoms
- psychosocial: behavioural symptoms, emotions (reminiscence, validation, psychotherapy, stimulation/sensory integration), stimulation (e.g. art, pets), cognition
- future: b-secretase inhibitors, g-secretase inhibitors, a-secretase promotors, anti-aggregants,
- PD drugs can worsen dementia, APDs can worsen PD esp. halo, chlorpro, sulpiride
dementia - DDx
MCI: 10-15% develop dementia delirium pseudodementia, depression iatrogenic: med SE infection nutrition: B12, B1, B9 metabolic: hypothyroid SDH and tumours poison hydrocephalus learning difficulties
dementia - BPSDs
67-90% at some point
fluctuant
psychological: anxiety, depression, insomnia; halls/dels; misID (less common)
behavioural: apathy, aggro, wandering, restless, eating; agitated, pacing, screaming; crying, mannerisms
- AD: apathy, agitation, anx/depp, irritable
- VD: apathy, depp, delusions
- LBD: halls/dels, depp, sleep
- FTD: apathy, disinhibition, elation, obsession
carer burden, stress, CH/NH, worse functional impairment and mortality
dementia - BPSD Mx
ID triggers e.g. underlying need
PPH, life events, relationship status, MSE
exclude DDx: delirium, SE, psych
educate and counsel
non-pharma: communication, orientation, familiarity, senses, support, behavioural
pharma: last resort, NOT SEDATIVES; target e.g. sleep, depp, aggro (risperidone), constipation, pain
dementia - risks and ethics
driving, wandering, fires, falls, neglect, exploitation, abuse
driving/DVLA
disclosure (pros and cons)
Alzheimer’s - 62%
500,000 UK
98% cases are >90yo
STM first, then personality;
4 As: amnesia, agnosia, aphasia, apraxia
language, recognition, frontal lobes, emotions, senses, balance, ANS (late)
- phases prominent; variable course; LE 7y from Dx, 14y 3%
- RF: lipid, HTN, DM, smoking; ?diet/exercise/NSAIDs
Vascular dementia - 17%
- M>F; 2nd commonest; types: post-stroke, multi-infarct, small vessel disease, subcortical, mixed (cortical/subcortical)
- ?preventable: vascular risk factors
-RFs: smoking, alcohol, diet/weight/exercise, HTN, lipids, atherosclerosis, CVD, TIA, DM, age
- similar to AD, ‘stepwise’ classical but not often present
- memory, communication, concentration; seizures, incontinence, stroke; depression/lability, behaviour; visual/perceptual;
- early gait disturbance (unsteady/falls) - ?cerebral hypoperfusion
- BV damage on imaging (hge, infarcts, ventricular dilation)
FTD 2%
more common >65yo
many subtypes e.g. Pick’s
insidious, gradual progression
behaviour then cognitive
frontal lobe: personality, emotion, behaviour, hyperphagia, loss of abstract language, disinhibition, primitive reflexes
temporal lobe: language (word finding), echolalia, mutism, perseveration
memory changes later; also hypotension, primitive reflexes, incontinence, akinesia and tremor
3 variants/presentations:
- behavioural
- progressive non-fluent aphasia
- semantic
LBD 4%; 25,000 UK
PDD 2%; 30% of PD; 2y PD before dementia
similar to AD: memory, attn, communication
interpatient variability
core features:
- memory;
- hallucinations (vusual, complex, +/- delusions; 75%);
- fluctuant attention;
- parkinsonism (before/after)
associated: syncope/falls, autonomic dysfunction (hypoTN), neuroleptic sensitivity (PD and NMS risk), REM sleep behaviour disorder
dementia - assessment
history: onset and progression, symptoms, drugs and substances
examination: CVS, neuro (incl. gait and movement), thyroid, liver, MSE, cognitive, co-morbidity (ADLs, GDS, HAP, NPI)
investigations: bloods: baseline, B12, Ca ECG + microbiology neuroimaging (CT 1st line) ?EEG
dementia RF
smoking and alcohol atherosclerosis hypercholesterolaemia: VD and AD age genetics MCI
dementia - types
aetiology:
degenerative: alzheimer’s, PD/LBD, Huntington’s, FTD, progressive supranuclear palsy
vascular: multi-infarct, cerebral infarcts, CADASIL, vasculitis (e.g. Lupus)
trauma: head injury, boxing, repeated concussions
intracranial malignancy: primary or metastatic
hydrostatic: hydrocephalus
infection: syphilis, HIV, cryptococcus, CJD
toxic/endocrine/metabolic: inherited (Wilson’s), alcohol/drugs, heavy metals, hypothyroid, B12/folate, paraneoplastic
anoxia: cardiac arrest
pathology: tau: AD, FTD, PSP synuclein: LBD, PDD vascular: VD mixed secondary: CJD, HD, injury reversible: vasculitis, infection, metab, vit, hydroceph environmental: poison, substances, anoxia
dementia - pathophysiology
general:
- frontal: personality, reasoning/decisions, inhibition, abstract thought, planning, problem solving, judgement
- parietal: visuospatial, clumsy, planning, recognition, action sequencing
- temporal: attention, memory, speech
AD:
-BA plaques (cell apoptosis/lost synapses) and intraneuronal tau tangles (microtubules - communication);
-atrophy (parietal, frontal, cingulate, hippocampus, locus coeruleus);
-large ventricles
VD:
-infarcts, hge, ventricular dilatation
LBD:
-intraneural spherical a-Synuclein protein deposits; prevent NT signalling
-SN: classical (PD); or cortical; DAT scan shows striatal loss (PD vs. ET, LBD vs. AD)
-atrophy: parietal, temporal, cingulate
-loss of ACH neurons in basal nucleus of Meynert
FTD:
-tau proteins; Pick’s = intraneural deposits
-50% inherited
dementia - phases
early:
- ST memory loss, confusion/disorientation, losing objects
- difficulty with change, an judgment incl. finances
- minor functional behavioural
middle:
- ADLs
- people recognition
- increased forgetfulness
- disorientation, hallucinations
- frustration, aggression, self-confidence
late:
- dependence: incontinence, eating/drinking, frailty, movement/psychomotor
- speech/language incl. understanding
- behaviour: aggression, restlessness, distressed, agitation
- weight loss and dysphagia, malnutrition
dementia - management
BPS approach
carer support important
medications to improve cognition
medications to relieve symptoms
medications to reduce comorbidity and risk factors
psychosocial:
- behavioural approach (BPSD)
- emotion: reminiscence, validation, supportive, therapy, sensory integration, stimulation
- cognition: orientation, retraining
- stimulation: art, music, pet, exercise, recreation
support: patient and carer
