9 - Dementia and Delirium Flashcards
How can you distinguish between dementia and delirium:
Sleep-wake cycle
Attention
Arousal
Autonomic Features
Duration
Delusions
Course
Conscious level
Collateral history is key to distinguishing delirium from dementia!!!
How can you distinguish between dementia and delirium:
- Hallucinations
- Rate of onset
- Psychomotor activity
What are some common causes of delirium?
- Constipation
- Hypothermia
- Infections
- Metabolic disturbances
- Pain
- Environment
- Drugs
What routine investigations do you do for a patient with suspected delirium?
CONFUSION SCREEN
- Bloods (as below)
- Urinalysis (positive dipstick without clinical signs is NOT satisfactory to diagnose UTI)
- +/- Imaging (e.g CXR or CT head)
What are some of the tools for assessing cognition to screen for delirium and dementia?
- CAM (best for delirium)
- MMSE
- AMT
How do you use the CAM tool?
For a diagnosis of delirium by CAM, the patient must display:
- Acute onset and fluctuating course (Collateral History)
- Inattention (count back from 20 to 1)
AND EITHER
3. Disorganized thinking
OR
4. Altered level of consciousness
How do you do a MMSE?
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
How do you do a AMTS?
Score less than 8 suggests cognitive impairment
How do you do a 4AT assessment?
Assessment for delirium
4 A’s
What is a MoCA score?
Montreal Cognitive Assessment
26 or more = Normal
18 to 25 = Mild Cognitive Impairment
10-17 = Moderate Cognitive Impairment
<10 = Severe cognitive Impairment
How may somebody with delirium present?
- Agitated
- Disorientation
- Hallucinations
- Inattention
- Memory problems
- Change in mood or personality
- Disturbed sleep
How do you manage a patient with delirium?
- 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 (use lorazepam if patient has Parkinson’s)
- Prevention
What are some risks of using haloperidol and antipsychotics in the treatment of delirium?
- 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
What is the definition of dementia?
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
What are some communication tips when taking a history from a dementia patient?
- 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
What are some challenging behaviours in dementia and how can they be managed non-pharmacologically?
- Wandering
- Restlessness
- Agitation
- Incontinence
- Perseveration (repetition)
- Paranoia
- Sleeplessness/’sundowning’
- Hallucinations
- Physically or sexually inappropriate behaviour
Try to identify triggers. VERA
What are some tools that can be used to aid diagnosis of dementia?
6CIT
GPCOG
7 minute screen
Fill out the following boxes for Alzheimer’s Dementia:
- Prevalence
- Pathogenesis
- Disease progression
- Risk Factors
- Diagnostic Criteria
- Management
What are some genes associated with Alzheimer’s?
- Amyloid Precursor Protein (APP)
- Presenilin (PSEN1/PSEN2)
Neurofibrillary tangles and Senile plaques are associated with aging, what makes them different in Alzheimer’s disease?
Located mainly in hippocampus and medial temporal lobes
What are the first signs of Alzheimer’s disease and some symptoms that occur as the disease becomes established?
Early impairment of memory. Manifests as short-term memory loss and difficulty learning new information
- Cognitive impairment
- Behaviour and Psychological Symptoms of Dementia (BPSD)
What are the different cognitive domains?
- Attention – The ability to focus on specific stimuli or tasks while ignoring distractions. Includes sustained attention, selective attention, and divided attention.
- Memory – Encompasses different types of memory, including short-term memory, working memory, and long-term memory (episodic, semantic, and procedural memory).
- Executive Function – Involves higher-level processes like planning, problem-solving, decision-making, reasoning, and cognitive flexibility.
- Language – Covers abilities related to understanding and producing spoken and written language, including vocabulary, grammar, and comprehension.
- Visuospatial Skills – The capacity to perceive, analyze, and interpret spatial relationships, such as recognizing objects, navigating environments, and understanding geometric relationships.
- Processing Speed – The rate at which cognitive tasks are completed, affecting reaction time, problem-solving, and learning efficiency.
What is the ACE-III tool?
What is the cut off for dementia?
What does mild cognitive impairment mean?
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
How is the severity of dementia determined?
CDR = Clinical Dementia Rating
What are some baseline investigations you may do when you want to rule out other causes of dementia symptoms?
- MRI or CT: can look for small vessel disease if vascular dementia
Imaging for vascular dementia?
- MRI or CT: can look for small vessel disease if vascular dementia
MRI (Preferred Modality)
1. White Matter Hyperintensities (WMH) – Bright areas on T2/FLAIR, indicating small vessel disease.
2. Lacunar Infarcts – Small, deep brain infarcts affecting cognition.
3. Cortical & Subcortical Infarcts – Larger strokes that contribute to cognitive impairment.
4. Microbleeds – Seen on SWI/GRE, often linked to cerebral amyloid angiopathy.
5. Brain Atrophy – Subcortical or generalized, depending on extent of vascular damage.
CT (Used for Initial Screening)
1. Larger Infarcts or Hemorrhages – Helps detect recent strokes.
2. Leukoaraiosis (White Matter Changes) – Seen as hypodense (dark) areas.
3. Brain Atrophy – Less sensitive than MRI but still visible.
What is the prognosis with Alzheimer’s disease?
Alzheimer’s Disease (AD)
• Progression: Slow and steady decline over 8–12 years on average.
• Early symptoms: Memory loss, word-finding difficulties.
• Later stages: Severe cognitive impairment, loss of motor function, and dependency on caregivers.
• Life expectancy: 4–12 years after diagnosis.
Fill out the following boxes for Vascular Dementia:
- Prevalence
- Pathogenesis
- Disease progression
- Risk Factors
- Diagnostic Criteria
- Management
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
- 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)
What is cerebral amyloid?
- Type of small vessel disease in the brain
- Deposition of amyloid in small arteries
What is CADASIL?
- 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
What is the DSM-V criteria for dementia?
How should you nutritionally care for someone with dementia?
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
How may Lewy Body Dementia present?
- Visual hallucinations
- Parkinson-like symptoms
- Fluctuating cognition
- Sleep disorders
- Autonomic dysfunction
Decline before parkinson’s symptoms
What are the differences between Lewy Body Dementia and Alzheimer’s?
Fill out the following boxes for Lewy Body Dementia:
- Prevalence
- Pathogenesis
- Disease progression
- Risk Factors
- Diagnostic Criteria
- Management
Must have dementia before movement disorder or at same time as to be this and not Parkinson’s dementia
What is the most to least common dementia?
Fill out the following boxes for Frontotemporal Dementia:
- Prevalence
- Pathogenesis
- Disease progression
- Risk Factors
- Diagnostic Criteria
What are the subtypes of frontotemporal dementia?
- 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
What are some genes that are involved in frontotemporal dementia?
- Microtubule associated protein tau (MAPT)
- Granulin precursor (GRN)
- C9ORF72 gene: most common
What is the clinical presentation of Frontotemporal dementia?
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)
What are some motor syndromes that FTD may appear alongside?
- FTD with motor neuron disease
- Corticobasal syndrome
- Progressive supra nuclear palsy
What may neuroimaging of FTD show?
Fill out the following boxes for Parkinson’s dementia:
- Prevalence
- Pathogenesis
- Disease progression
- Risk Factors
- Diagnostic Criteria
- Pathogenesis:
PDD results from the spread of α-synuclein aggregates (Lewy bodies) from the substantia nigra to the cortex, leading to dopaminergic and cholinergic deficits. Neuroinflammation, oxidative stress, and Alzheimer’s co-pathology contribute to cognitive decline. - Disease Progression:
• Early Stage: Predominantly motor symptoms; mild cognitive impairment (MCI) affecting attention and executive function.
• Intermediate Stage: Worsening cognition, memory loss, visuospatial deficits, hallucinations, and psychiatric symptoms.
• Advanced Stage: Severe dementia, fluctuating attention, significant functional decline, and psychosis. - Diagnostic Criteria (MDS Guidelines):
• Core Features: Established Parkinson’s disease, cognitive decline in at least two domains, and impairment of daily activities.
• Supportive Features: Hallucinations, cognitive fluctuations, REM sleep disturbances, depression, or apathy.
• Exclusion: Dementia occurring before or within one year of motor symptoms suggests Dementia with Lewy Bodies (DLB) instead.
Key Differentiation:
• PDD: Motor symptoms precede dementia (>1 year).
• DLB: Dementia occurs before or with motor symptoms.
What are some causes of reversible dementia symptoms?
- Normal Pressure Hydrocephalus!
- Depression
- B12 Deficiency
- Neurosyphillis
- Space occupying lesion
- Alcohol abuse
What are some rare causes of dementia?
- CJD
- HIV
- Syphillis
- Huntington’s
How quickly does CJD progress?
What is normal pressure hydrocephalus and how does it present and how is it managed?
Build-up of CSF in the ventricles causes increased pressure, producing symptoms of cognitive impairment, gait disturbance and urinary incontinence
Wacky, Wobbly, Wet
Ventriculoperitoneal shunt
What is pseudo dementia and how can you spot this?
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
What are some preventable causes of dementia?
- Metabolic & Nutritional Causes
• Vitamin B12 Deficiency – Leads to cognitive decline and neuropathy
• Thiamine Deficiency (Wernicke-Korsakoff Syndrome) – Often due to chronic alcoholism
• Hypothyroidism – Slowed metabolism affects cognition and memory
• Electrolyte Imbalances – Hyponatremia, hypercalcemia can cause confusion
• Hypoglycemia & Diabetes – Glucose dysregulation affects brain function - Infections
• Neurosyphilis – Late-stage syphilis can lead to cognitive impairment
• HIV/AIDS-Associated Dementia – Opportunistic infections contribute
• Lyme Disease – Neuroborreliosis can mimic dementia
• Chronic Meningitis – Tuberculosis, fungal, or cryptococcal infections - Toxic & Drug-Induced Causes
• Medication Side Effects – Anticholinergics, benzodiazepines, opioids, sedatives
• Chronic Alcohol Use (Alcohol-Related Dementia) – Leads to cognitive impairment
• Heavy Metal Toxicity – Lead, mercury, arsenic exposure - Structural & Hydrocephalic Causes
• Normal Pressure Hydrocephalus (NPH) – Treatable with shunting
• Brain Tumors – Can cause pressure-related cognitive decline
• Subdural Hematoma – Chronic bleeding in older adults can lead to confusion - Autoimmune & Inflammatory Causes
• Lupus Cerebritis (SLE) – Can cause cognitive dysfunction
• Multiple Sclerosis (MS) – Cognitive impairment in some cases
• Paraneoplastic Syndromes – Associated with cancer-related immune responses - Psychiatric Causes
• Depression (Pseudodementia) – Cognitive impairment in major depressive disorder can mimic dementia but improves with treatment
• Chronic Anxiety & Stress – Long-term effects on cognition
What are some baseline bloods you should do if you suspect a patient has dementia?
What are some memory tests you can do over the phone during COVID times?
- Blind MoCA
- TICS (Telephone Interview for Cognitive Status)
- Tele-Test Your Memory (TYM)
What changes on a CT of a patient with Alzheimer’s might you see?
MRI is favoured
- Cortical atrophy
- Temporal lobe atrophy (especially hippocampus)
- Widening of ventricles
What is the Abbey Pain Scale for dementia patients?
Used for dementia patients who cannot verbalise
What are these used for?
• PAINAD (Pain Assessment in Advanced Dementia Scale) – Observes breathing, vocalizations, facial expressions, body language, and consolability.
• Abbey Pain Scale – Common in non-verbal patients, assessing facial expressions, behavior, and physiological changes.
• FLACC Scale – Originally for children but used in dementia, evaluating Face, Legs, Activity, Cry, and Consolability.
Used for dementia patients who cannot verbalise
How can you take a collateral history from a family member for a patient with dementia?
IMPORTANT IMAGE!!!
Always find out relation to patient first!
What are the different ADLs?
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
How can you set up a risk assessment for a dementia patient?
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,
What is the prognosis of Vascular dementia?
Vascular Dementia (VaD)
• Progression: Stepwise decline due to repeated strokes or infarcts.
• Symptoms: Vary based on stroke location; can include motor deficits, slowed thinking, and executive dysfunction.
• Life expectancy: 5–10 years, often shorter than AD due to cardiovascular comorbidities.
What is the prognosis of Dementia with Lewy Bodies?
Dementia with Lewy Bodies (DLB)
• Progression: Faster than AD, typically over 5–8 years.
• Symptoms: Visual hallucinations, fluctuating cognition, Parkinsonism, REM sleep disturbances.
• Life expectancy: 5–7 years after diagnosis, with high risk of complications like pneumonia.
What is the prognosis of Frontotemporal dementia?
Frontotemporal Dementia (FTD)
• Progression: Rapid, often over 6–10 years.
• Symptoms: Early personality changes, disinhibition, language impairment (if primary progressive aphasia).
• Life expectancy: 6–10 years, with some aggressive variants progressing faster
