3 Ds - Delirium, dementia, depression Flashcards
delirium - features
- 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%
delirium - RF/triggers
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
delirium - assessment approach
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
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 (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
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
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
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
29% acute med IP
40-45% post-stroke
85% also have anxiety
25% of suicides are elderly
10-20% have delirium
Depression presentation
- Reduction in activity
- Depressive and suicidal thoughts
- Agitation
- Psychosomatic complaints
- Poor memory
- Self neglect
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 aetiology
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
depression - management
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
depression - history
HPC:
- onset
- Sx
- triggers/RF
- coping mechs
- alcohol/substance
- risk/insight
depression - RF/triggers
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
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
assess the four cognitive domains
- amnesia
- agnosia
- aphasia
- apraxia
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,
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)
Frptotemporal demetia: 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
dementia - DDx
- 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
dementia - BPSDs (behavioural and psychologial symptoms of depression) 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:
- -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
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
