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Year 3 Medicine > 9 - Dementia and Delirium > Flashcards

9 - Dementia and Delirium Flashcards

1
Q

How can you distinguish between dementia and delirium:

Sleep-wake cycle
Attention
Arousal
Autonomic Features
Duration
Delusions

Course

Conscious level

A

Collateral history is key to distinguishing delirium from dementia!!!

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2
Q

How can you distinguish between dementia and delirium:

  • Hallucinations
  • Rate of onset
  • Psychomotor activity
A
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3
Q

What are some common causes of delirium?

A
  • Constipation
  • Hypothermia
  • Infections
  • Metabolic disturbances
  • Pain
  • Environment
  • Drugs
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4
Q

What routine investigations do you do for a patient with suspected delirium?

A

CONFUSION SCREEN

  • Bloods
  • Urinalysis
  • ?Imaging
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5
Q

What are some of the tools for assessing cognition to screen for delirium and dementia?

A
  • CAM (best for delirium)
  • MMSE
  • AMT
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6
Q

How do you use the CAM tool?

A

For a diagnosis of delirium by CAM, the patient must display:

  1. Acute onset and fluctuating course (Collateral History)
  2. Inattention (count back from 20 to 1)

AND EITHER
3. Disorganized thinking
OR
4. Altered level of consciousness

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7
Q

How do you do a MMSE?

A

Assess level of cognitive impairment

25-30 = Normal

21-24 = Mild

10-20 = Moderate

<10 = Severe

Cannot use if communication difficulties e.g learning disability

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8
Q

How do you do a AMTS?

A

Score less than 8 suggests cognitive impairment

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9
Q

How do you do a 4AT assessment?

A

Assessment for delirium

4 A’s

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10
Q

How do you do a 4AT assessment?

A

Assessment for delirium

4 A’s

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11
Q

What is a MoCA score?

A

Montreal Cognitive Assessment

26 or more = Normal

18 to 25 = Mild Cognitive Impairment

10-17 = Moderate Cognitive Impairment

<10 = Severe cognitive Impairment

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12
Q

How may somebody with delirium present?

A
  • Agitated
  • Disorientation
  • Hallucinations
  • Inattention
  • Memory problems
  • Change in mood or personality
  • Disturbed sleep
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13
Q

How do you manage a patient with delirium?

A
  • Find and treat underlying cause
  • Supportive: clocks, familiar objects, visual/hearing/walking aids, side room so less noise, continuous care
  • Medication: only if essential use small doses of haloperidol
  • Prevention
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14
Q

What are some risks of using haloperidol and antipsychotics in the treatment of delirium?

A
  • Cardiovascular issues (do ECG as can cause long QT, Vtach and sudden death)
  • Extrapyramidal symptoms
  • Sedation
  • Anticholinergic effects including increased confusion, cardiovascular effects and tardive dyskinesia
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15
Q

What is the definition of dementia?

A

Syndrome of generalised decline in memory, intellect and personality without impairment of consciousness that leads to issues with performing ADLs

Impairment of function e.g retaining new information, managing complex tasks, language and word finding, behaviour, recognition, ability to self care, reasoning

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16
Q

What are some communication tips when taking a history from a dementia patient?

A
  • Redirection not correction
  • Consistent schedules
  • Approach from the front
  • Ensure they have their hearing and visual aids
  • Keep it simple
  • Avoid lots of direct questions
  • Get collateral history
  • Validation
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17
Q

What are some challenging behaviours in dementia and how can they be managed?

A
  • Wandering
  • Restlessness
  • Agitation
  • Incontinence
  • Perseveration (repetition)
  • Paranoia
  • Sleeplessness/’sundowning’
  • Hallucinations
  • Physically or sexually inappropriate behaviour

Try to identify triggers. VERA

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18
Q

What are some tools that can be used to aid diagnosis of dementia?

A

6CIT

GPCOG

7 minute screen

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19
Q

Fill out the following boxes for Alzheimer’s Dementia:

  • Prevalence
  • Pathogenesis
  • Disease progression
  • Risk Factors
  • Diagnostic Criteria
  • Management
A
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20
Q

What are some genes associated with Alzheimer’s?

A
  • Amyloid Precursor Protein (APP)
  • Presenilin (PSEN1/PSEN2)
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21
Q

Neurofibrillary tangles and Senile plaques are associated with aging, what makes them different in Alzheimer’s disease?

A

Located mainly in hippocampus and medial temporal lobes

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22
Q

What are the first signs of Alzheimer’s disease and some symptoms that occur as the disease becomes established?

A

Early impairment of memory. Manifests as short-term memory loss and difficulty learning new information

  • Cognitive impairment
  • Behaviour and Psychological Symptoms of Dementia (BPSD)
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23
Q

What are the different cognitive domains?

A
  • Attention and concentration
  • Recent and remote memory
  • Language
  • Praxis: planned motor movement (e.g. perform a task)
  • Executive function
  • Visuospatial function
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24
Q

What is the ACE-III tool?

A
25
Q

What does mild cognitive impairment mean?

A

Cognitive deficits in one or more of the major cognitive domains, but deficit is insufficient to interfere with independence in daily activities.

High risk of dementia so follow up

26
Q

How is the severity of dementia determined?

A

CDR = Clinical Dementia Rating

27
Q

What are some baseline investigations you may do when you want to rule out other causes of dementia symptoms?

A
  • MRI or CT: can look for small vessel disease if vascular dementia
28
Q
A
  • MRI or CT: can look for small vessel disease if vascular dementia
29
Q

What is the prognosis with dementia?

A

No cure, usually survive 3-9 years after diagnosis

If you get a delirium on top will rapidly progress dementia

30
Q

Fill out the following boxes for Vascular Dementia:

  • Prevalence
  • Pathogenesis
  • Disease progression
  • Risk Factors
  • Diagnostic Criteria
  • Management
A

tt

31
Q

Vascular dementia is a spectrum of dementias caused by CVD. What are the definitions of the following classifications of VD?

  • Subcortical VD
  • Stroke-related VD
  • Single or Multiinfarct VD
  • Mixed dementia
A
  • Subcortical VD: Dementia caused by disease affecting the small vessels of the brain which predominantly supply the subcortical white matter
  • Stroke-related VD: Development of dementia following a large cortical stroke. Up to 20% develop this within the next 6 months
  • Single or multi-infarct VD: Development of dementia following a single, or multiple small strokes. It is the collective burden of cerebrovascular disease from these strokes that precipitates development of dementia
  • Mixed dementia: Features of more than one type of dementia (usually VD and AD)
32
Q

What is cerebral amyloid?

A
  • Type of small vessel disease in the brain
  • Deposition of amyloid in small arteries
33
Q

What is CADASIL?

A
  • Autosomal dominant
  • ‘cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy’
  • Mutation in the NOTCH3 gene and leads to arterial thickening and occlusion.
  • Recurrent migraine-type headaches, multiple strokes and progressive dementia starting in 50’s
34
Q

What is the DSM-V criteria for dementia?

A
35
Q

How should you nutritionally care for someone with dementia?

A

Keep them oral as long as possible

Do not long term feed with NG tubes as no evidence of increased survival and no evidence it reduces aspiration

36
Q

How may Lewy Body Dementia present?

A
  • Visual hallucinations
  • Parkinson-like symptoms
  • Fluctuating cognition
  • Sleep disorders
  • Autonomic dysfunction

Decline before parkinson’s symptoms

37
Q

What are the differences between Lewy Body Dementia and Alzheimer’s?

A
38
Q

Fill out the following boxes for Lewy Body Dementia:

  • Prevalence
  • Pathogenesis
  • Disease progression
  • Risk Factors
  • Diagnostic Criteria
  • Management
A

Must have dementia before movement disorder or at same time as to be this and not Parkinson’s dementia

39
Q

What is the most to least common dementia?

A
40
Q

Fill out the following boxes for Frontotemporal Dementia:

  • Prevalence
  • Pathogenesis
  • Disease progression
  • Risk Factors
  • Diagnostic Criteria
A
41
Q

What are the subtypes of frontotemporal dementia?

A
  • Behavioural variant: most common. Occurs in 50%. Progressive personality and behaviour change
  • Primary progressive aphasia: insidious onset of progressive language defects (e.g. word finding, aphasia)
  • Non-fluent PPA: characterised by articulatory difficulty
  • -Semantic PPA*: characterised by impaired single-word comprehension
42
Q

What are some genes that are involved in frontotemporal dementia?

A
  • Microtubule associated protein tau (MAPT)
  • Granulin precursor (GRN)
  • C9ORF72 gene: most common
43
Q

What is the clinical presentation of Frontotemporal dementia?

A

Behavioural Variant

  • Disinhibition (e.g. socially inappropriate behaviour)
  • Loss of empathy
  • Apathy (losing interest and/or motivation)
  • Hyperorality (e.g. dietary changes, attempt to consume non-edible products, eat beyond satiety)
  • Compulsive behaviour (e.g. cleaning, checking, hoarding)

Primary progressive aphasia

  • Effortful speech
  • Halting speech
  • Speech-sound errors
  • Speech apraxia (i.e. difficulty in articulation)
  • Word-finding difficulty
  • Surface dyslexia or dysgraphia: mispronouncing difficult words (e.g. yacht)
44
Q

What are some motor syndromes that FTD may appear alongside?

A
  • FTD with motor neuron disease
  • Corticobasal syndrome
  • Progressive supra nuclear palsy
45
Q

What may neuroimaging of FTD show?

A
46
Q

Fill out the following boxes for Parkinson’s dementia:

  • Prevalence
  • Pathogenesis
  • Disease progression
  • Risk Factors
  • Diagnostic Criteria
A
47
Q

What are some causes of reversible dementia symptoms?

A
  • Normal Pressure Hydrocephalus!
  • Depression
  • B12 Deficiency
  • Neurosyphillis
  • Space occupying lesion
  • Alcohol abuse
48
Q

What are some rare causes of dementia?

A
  • CJD
  • HIV
  • Syphillis
  • Huntington’s
49
Q

How quickly does CJD progress?

A
50
Q

What is normal pressure hydrocephalus and how does it present and how is it managed?

A

Build-up of CSF in the ventricles causes increased pressure, producing symptoms of cognitive impairment

Wacky, Wobbly, Wet

Ventriculoperitoneal shunt

51
Q

What is pseudo dementia and how can you spot this?

A

Cognitive deficits in older patients with depression

  • Short duration of dementia
  • Equal effect on long and short term memory
  • Amnesia concerning specific events
  • Often patient will very detailed complaint about memory disturbance
  • Patient may highlight failures in answers to questions relating to memory
  • Loss of social skills early in the illness
  • Patient will often answer “don’t know” to questions, as opposed to guessing close answers
  • Patient may make little effort in performing tasks
52
Q

What are some preventable causes of dementia?

A
  • Social contact
  • Education
  • Exercise in midlife
  • Avoid smoking
53
Q

What are some baseline bloods you should do if you suspect a patient has dementia?

A
54
Q

What are some memory tests you can do over the phone during COVID times?

A
  • Blind MoCA
  • TICS (Telephone Interview for Cognitive Status)
  • Tele-Test Your Memory (TYM)
55
Q

What changes on a CT of a patient with Alzheimer’s might you see?

A

MRI is favoured

  • Cortical atrophy
  • Temporal lobe atrophy (especially hippocampus)
  • Widening of ventricles
56
Q

What is the Abbey Pain Scale for dementia patients?

A

Used for dementia patients who cannot verbalise

57
Q

How can you take a collateral history from a family member for a patient with dementia?

IMPORTANT IMAGE!!!

A

Always find out relation to patient first!

58
Q

What are the different ADLs?

A

Basic

  • Toileting
  • Mobility
  • Personal Hygiene
  • Feeding
  • Dressing
  • Continence

Instrumental

  • Transportation and shopping
  • Managing finances
  • Shopping and meal preparation
  • Housecleaning and home maintenance
  • Managing communication with others
  • Managing medications
59
Q

How can you set up a risk assessment for a dementia patient?

A

Always think about risk to themselves but also risk to others

e.g hot water, leaving gas on, hazardous items like grass cutter, cars, leaving the house without you knowing,

Year 3 Medicine (15 decks)

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