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CP2 HCOLL > 3 Ds - Delirium, dementia, depression > Flashcards

3 Ds - Delirium, dementia, depression Flashcards

1
Q

delirium - features

A
  • acute onset
  • fluctuating course
  • disorganised thinking
  • altered level of consiousness
  • inattention and distractability
  • underlying medical cause (usually)

imparied cognition associated with an affective disorder or psychosis

secondary cause other: emotions, behaviours, hypo/hyperactive, perception changes

hypo 40%, hyper 25%, mixed 35%

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2
Q

delirium - RF/triggers

A

RF:

  • dementia
  • frail
  • age
  • co-morbidities
  • sensory impairment

Precipitating factors

  • drug initiation
  • medical illness
  • systemic infection
  • metabolic derangement
  • surgery
  • pain
  • brain disorders (stroke/seizures)
  • systemic organ failure
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3
Q

delirium - assessment approach

A

history and collateral

exam: obs, sepsis, MSK, neuro, sensory, PR

first line investigations

  • White Blood cells/CRP (infection)
  • U and Es
  • LFTs
  • Glucose
  • TFTs
  • Chest X-ray
  • Urinalysis
  • ECG

Second line investigations

  • ABGs
  • serum calcium B12 and folate
  • specimum cultures
  • CT/MRI head
  • Electroencephalogram
  • CSF
  • Toxicology
  • Bladder scan for retention
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4
Q

delirium - aetiology

A

‘DELIRIUM’:

drugs, electrolytes, lack of drugs, infection, reduced senses, intracranial, urinary retention, myocardial

also:

trauma, hypoxia, vascular, toxins/heavy metals, sleep, anx/depp

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5
Q

delirium - prognosis

A

increased mortality (60% more likely at 1y)

33% persist at one month and 20% never recover

longer hospitalisation

institutionalisation

eightfold increased risk of going on to develop dementia within 3 years

reduced function/incomplete recovery

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6
Q

delirium - epidemiology

A

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!!

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7
Q

delirium - management

A

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

Medication: should be avoided but Hloperidol and lorazepam orally or im - for short term control of distess when imediate risk/danger

environment: calm, familiar, orientating, big signs
treatment: reassure safety, minimally invasive (no lines), rehydrate, nutrition, bowels, meds, mobility, senses

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8
Q

delirium - DDx

A

dementia: chronic, general function and IQ
psychiatric: psychosis (e.g. schizophrenia or depression)

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9
Q

depression - epidemiology

A

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

29% acute med IP

40-45% post-stroke

85% also have anxiety

25% of suicides are elderly

10-20% have delirium

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10
Q

Depression presentation

A
  • Reduction in activity
  • Depressive and suicidal thoughts
  • Agitation
  • Psychosomatic complaints
  • Poor memory
  • Self neglect
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11
Q

depression - features

A
  • 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’
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12
Q

depression - suicide features

A
  • 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

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13
Q

Depression aetiology

A

Biological

  • chronic pain
  • long term conditions
  • recent physical illness
  • medications (steroids)

Psychological

  • previous history of depression or anxiety
  • loss
  • high level of independence

Social

  • social isolation
  • widowed
  • not able to drive/poor mobility
  • elderly neighbours
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14
Q

depression - management

A

bio:

  • ADD (SSRIs)
  • anxiolytics - benzos
  • hypnotics - z drugs
  • review every 2-4 week?
  • investigations - FBC U&E LFT calcium levels etc

psycho:

  • education
  • CBT
  • supportive listening

social:

  • carer support (e.g. respite)
  • diet
  • exercise
  • support groups
  • social service referal
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15
Q

depression - history

A

HPC:

  • onset
  • Sx
  • triggers/RF
  • coping mechs
  • alcohol/substance
  • risk/insight
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16
Q

depression - RF/triggers

A

triggers:

  • life events
  • health
  • stress
  • somatisation

risk factors:

  • PMH/FH
  • poor physical health
  • loss of health/mobility
  • poverty
  • institutionalised
  • widow/er
  • alone/isolate
  • poor social support
  • no confidant
  • personality
  • recent loss/bereavement
  • retirement
  • some medications
17
Q

depression - HCE differences

A

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

18
Q

depression - types

A

mild/moderate/severe +/- psychotic
recurrent depressive
BAD
organic depressive episode
mixed anx/depp
dysthymia
adjustment disorder
minor depressive disorder

19
Q

depression - impact

A

physical health/neglect

QoL/ADL/function

slower recovery

morbidity and mortality

20
Q

dementia - definition/diagnosis

A

“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

assess the four cognitive domains

  • amnesia
  • agnosia
  • aphasia
  • apraxia
21
Q

dementia - stats

A

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,

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

22
Q

dementia - genetics

A

early-onset AD: rare; APP, presenilin 1/2; onset 30-40y; 2x FHX

late-onset AD: apoE4 or apoE3 (more stats)

Frptotemporal demetia: MAPP, GRN, TAU

23
Q

dementia - features

A

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
24
Q

dementia - drugs/medications

A

AchE: increase ACH, increase NT; may slow progression; donepezil, galantamine, rivastigmine

NMDA: blocks glutamate, reduces toxic overstimulation and degeneration;

antipsychotics: symptoms

25
Q

dementia - DDx

A
  • MCI ( mild cognitive impairment): 10-15% develop dementia
  • delirium
  • pseudodementia, depression
  • iatrogenic: med SE
  • infection
  • nutrition: B12, B1, B9
  • metabolic: hypothyroid
  • SDH(subdural haematoma) and tumours
  • poison
  • hydrocephalus
  • learning difficulties
26
Q

dementia - BPSDs (behavioural and psychologial symptoms of depression) 67-90% at some point fluctuant

A

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

27
Q

dementia - BPSD Mx

A
  • 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
28
Q

dementia - risks and ethics

A
  • driving
  • wandering
  • fires
  • falls
  • neglect
  • exploitation
  • abuse driving/DVLA disclosure (pros and cons)
29
Q

Alzheimer’s - 62% 500,000 UK 98% cases are >90yo

A

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

30
Q

Vascular dementia - 17%

A
  • -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)
31
Q

FTD 2% more common >65yo many subtypes e.g. Pick’s

A
  • 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:
  1. -behavioural
  2. -progressive non-fluent aphasia
  3. -semantic
32
Q

LBD 4%; 25,000 UK PDD 2%; 30% of PD; 2y PD before dementia

A
  • 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
33
Q

dementia - assessment

A

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
34
Q

dementia RF

A
  • smoking and alcohol
  • atherosclerosis
  • hypercholesterolaemia: VD and AD
  • age
  • genetics
  • MCI
35
Q

dementia - types

A

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
36
Q

dementia - pathophysiology

A

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

37
Q

dementia - phases

A

early:

  • ST memory loss
  • confusion/disorientation,
  • losing objects
  • difficulty with change, an judgment incl. finances -
  • minor functional behavioural

middle:

  • -ADL
  • -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
38
Q

dementia - management

A

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

CP2 HCOLL (13 decks)

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