9. Confusion In The Elderly

Question 1

What are the cognitive symptoms of dementia?

Answer 1

Impaired memory
Impaired orientation
Impaired learning capacity
Impaired judgement

Question 2

What are the non-cognitive symptoms of dementia?

Answer 2

Behavioural symptoms - agitation, aggression, wandering, sexual disinhibition
Depression and anxiety
Psychotic features
Sleep symptoms - insomnia, daytime drowsiness

Question 3

What is the management for dementia?

Answer 3

Career support - OT, community services, ID bracelets

Pharmacological - cholinesterase inhibitors, antidepressants, antipsychotics

Question 4

What drugs can be used in dementia?

Answer 4

Acetylcholinesterase inhibitors - donepezil, rivatigmine, galantamine
NMDA antagonists - memantine

Question 5

What are the macroscopic pathological features of Alzheimer’s disease?

Answer 5

Global cortical atrophy
Sulcal widening
Enlarged ventricles

Question 6

What are the microscopic pathological features of Alzheimer’s disease?

Answer 6

Plaques - composed of amyloid beta

Tangles - hyperphosphorylated tau

Question 7

What are the risk factors for vascular dementia?

Answer 7

Previous stroke/MI
Hypertension 
Hypercholesterolaemia 
Diabetes 
Smoking

Question 8

What is the pathology of dementia with Lewy bodies?

Answer 8

Aggregation of alpha synuclein - forms spherical intracytoplasmic inclusions, main deposits found across the brain

Question 9

What is the presentation of dementia with Lewy bodies?

Answer 9

Fluctuating cognition and alertness
Vivid visual hallucinations
Parkinsonian features

Question 10

What can happen if patients with Lewy body dementia is given antipsychotics?

Answer 10

Neuroleptic malignant syndrome - fever, encephalopathy, vital signs instability, elevated creatine phosphokinase, rigidity

Question 11

What is frontotemporal dementia?

Answer 11

Frontal and temporal lobe atrophy

Question 12

What are the symptoms of frontotemporal dementia?

Answer 12

Behavioural disinhibition 
Inappropriate social behaviour
Loss of motivation without depression
Repetitive/ritualistic behaviours 
Non fluent aphasia

Question 13

What is the age onset peak of frontotemporal dementia?

Answer 13

Mid 50’s

Question 14

What is the pathology of AIDS dementia complex?

Answer 14

Entry of HIV infected macrophages into the brain is thought to lead to indirect damage of neurones

Question 15

What are the clinical features of AIDS dementia complex?

Answer 15

Cognitive impairment 
Psychomotor retardation
Tremor
Ataxia
Dysarthria
Incontinence

Question 16

How is dementia diagnosed?

Answer 16

Exclude organic causes of cognitive decline - hypothyroidism, hypercalcaemia, B12 deficiency, normal pressure by hydrocephalus
CT head
MRI brain
ECG in vascular dementia 
Mini mental state examination

Question 17

What is delirium?

Answer 17

Acute, fluctuating syndrome of disturbed consciousness, attention, cognition and perception

Question 18

What are the features of delirium?

Answer 18

Rapid onset of confusion
Clouded consciousness 
Fluctuating course
Maybe transient visual hallucinations
Often exaggerated emotional responses

Question 19

What a re the 3 different types of delirium?

Answer 19

Hyperactive - restless, agitated, aggressive
Hypoactive - withdrawn, quiet, sleepy
Mixed

Question 20

What are the causes of delirium?

Answer 20

Nutritional - vit deficiencies
Intracranial - stroke, TIAs, epilepsy, infection 
Extracranial infections - UTI, pneumonia
Iatrogenic - infections, drugs
Alcohol - intoxication, withdrawal
Endocrine - thyroid, pancreas
Metabolic - hypoxia, renal, hepatic

Question 21

What is the management for delirium?

Answer 21

Minimise/treat precipitating factors
Encourage normal day/night cycle
Allow wandering if safe
Consider DOLS (deprivation of liberty safeguards)
Involve family/loved ones
For challenging behaviours, distraction techniques, medications last resort