AC - Dementia & Delirium Flashcards
What is the definition of dementia?
Acquired impairment of higher mental functioning that impacts on social and occupational functioning must be associated with impairment
Difficulty in one or more of language, memory, learning, reasoning, spatial ability, behaviour
What is the definition of dementia?
Acquired impairment of higher mental functioning that impacts on social and occupational functioning must be associated with impairment
Difficulty in one or more of language, memory, learning, reasoning, spatial ability, behaviour
What is mild cognitive impairment?
MCI intermediate between normal & dementia, noticeable symptoms (patient has insight) but don’t impair function/fulfil criteria for dementia
Can impair in single or multiple domain, need to monitor as can progress to dementia
What are risk factors for dementia?
Risk factors CV risk factors, increasing age, family hx (if 1st degree with early onset, Down Syndrome (AD), excess alcohol intake (+ associated B12 deficiency), syphilis
What tools can be used to assess cognition?
MMSE RUDAS MoCA Clock test NuCOG
Describe features of MMSE
Describe features of RUDAS
Describe features of the clock test
Not specific to distinguish between dementias but highlights significant cognitive impairment
Issues with visuospatial planning, constructional praxis and executive function
Describe features of the clock test
Not specific to distinguish between dementias but highlights significant cognitive impairment
Issues with visuospatial planning, constructional praxis and executive function
What is mild cognitive impairment?
MCI intermediate between normal & dementia, noticeable symptoms (patient has insight) but don’t impair function/fulfil criteria for dementia
Can impair in single or multiple domain, need to monitor as can progress to dementia
Describe features of cholinesterase inhibitors in Rx dementia
Rivastigmine, donepezil
PBS for mild-moderate dementia
Beneficial in AD, LB dementia and PD with dementia
Symptomatic relief only no disease modification effect
Effect is individual (may not benefit, may have mild – moderate benefit)
Number to treat is the same as number to harm
Side effects Anti-SLUD bradycardia, fatigue, N+V, diarrhoea
What are some other possible clinical features of Alzheimer’s disease?
Apraxia
Attention & executive function issues can happen but are rare
Describe features of the clock test
Not specific to distinguish between dementias but highlights significant cognitive impairment
Issues with visuospatial planning, constructional praxis and executive function
What are the clinical features of vascular dementia?
Step wise progression - abrupt deterioration with stable periods between
Subcortical (similar to delirium) - slower processing, attention/concentration impairment, perseveration, initiation issues, motor signs (i.e. gait, incontinence), motor speech issues, unlikely memory issues (if present more short term recall issue than actually laying down new memories)
Cortical
- Frontal - executive dysfunction, aboulia, akinetic mutism
- Temporal - anterograde amnesia
- Left parietal - agnosia, aphasia, apraxia
- Right parietal - hemi-neglect, cortical sensory signs (i.e. graphesthesia), confusion, visuospatial issues
What are the main management principles of Dementia?
- Identify & modify any contributing/risk factors (i.e. drugs, alcohol, delirium, depression)
- Education, counselling and support
- Risk & driving assessment (personal safety, falls esp.)
- Non-pharmacological Rx - Memory aids, home&community ADL support, care in a safe, familiar environment, rationalise medications
- Pharm Rx - cholinesterase inhibitors, phosphodiesterase-4 inhibitors, NMDA receptor antagonist
Describe features of cholinesterase inhibitors in Rx dementia
Rivastigmine, donepezil
PBS for mild-moderate dementia
Beneficial in AD, LB dementia and PD with dementia
Symptomatic relief only no disease modification effect
Effect is individual (may not benefit, may have mild – moderate benefit)
Number to treat is the same as number to harm
Side effects Anti-SLUD bradycardia, fatigue, N+V, diarrhoea
Describe basic pathology of Alzheimer’s disease & imaging features
- alpha-beta protein forms insoluble sheets - aggregates - amyloid plaques
- TAU protein aggregations - neurofibrilary tangles
Begins in the HIPPOCAMPUS, later spreads to mesotemporal & parietal lobes
MRI - hippocampal atrophy, temporal lobe & cortical atrophy
PET - reduced glucose metabolism in temporal & parietal lobes, may detect amyloid plaques
What class of medication must be avoided in Lewy body dementia?
Antipsychotics (esp. typical) - cause EPSE
What is the classic clinical triad of Alzheimer’s disease?
- Memory - anterograde episodic - early and most dominant feature - late in disease long-term memory may be affected
- Visuospatial issues - i.e. getting lost in familiar areas
- Language - word finding difficulties (agnosia)
What are some other possible clinical features of Alzheimer’s disease?
Apraxia
Attention & executive function issues can happen but are rare
What are the pathological features of vascular dementia?
Caused by white matter lesions or stroke (cortical or subcortical)
MRI - white matter lesions, hyperintensities (T2/FLAIR), ventricle atrophy without cortical atrophy
What are the clinical features of vascular dementia?
Step wise progression - abrupt deterioration with stable periods between
Subcortical (similar to delirium) - slower processing, attention/concentration impairment, perseveration, initiation issues, motor signs (i.e. gait, incontinence), motor speech issues, unlikely memory issues (if present more short term recall issue than actually laying down new memories)
Cortical
- Frontal - executive dysfunction, aboulia, akinetic mutism
- Temporal - anterograde amnesia
- Left parietal - agnosia, aphasia, apraxia
- Right parietal - hemi-neglect, cortical sensory signs (i.e. graphesthesia), confusion, visuospatial issues
What is the basic pathology of Lewy body dementia?
Lewy body inclusions (made up of alpha-synuclein cytoplasmic proteins)
Distribution and density correlate to severity of clinical features
Commonly associated with amyloid pathology & AD
Cholinergic & dopamine deficits
MRI - mainly for exclusion of DDx - no clear patterns - hippocampus always spared (differentiate from AD)
What are risk factors of Lewy body dementia?
None that are known!
Clinical features of Lewy body dementia
- Fluctuations in cognition (similar to delirium) - attention and alertness
- Parkinsonism - often early and disabling
- Visual hallucinations - hallucinations of animals characteristic
What is the basic pathology of fronto-temporal dementia?
Tau protein accumulation - focal atrophy - gliosis (hyperplasia of glial cells)
Gliosis responsible for most of symptoms
Starts anteriorly (usually in frontal lobe, most common) Frontal - anterior parietal - temporal
MRI - focal atrophy, PET - focal hypometablism, SPECT - focal hypoperfusion
What are risk factors of fronto-temporal dementia?
GENETIC - strong FHx
What are the early signs of fronto-temporal dementia?
- Emotional and mood disturbance - depression, anxiety, increased sentimentality
- Social conduct issues
- Impaired insight
Precede cognitive issues (memory, disorientation) and apraxia
What clinical features of fronto-temporal dementia?
Frontal - behavioural variant - more common
Temporal - language variant - less common
Frontal - Impaired insight, judgement, disinhibition, executive dysfunction, motor signs (parkinsons, MND…), perseveration, apathy
Temporal - Broca’s aphasia, memory
What advice about driving do you give to person with new dementia diagnosis?
- May not have to give up license straight away due to slow nature of progression of disease
- Need to inform VicRoads themselves (drs can do this ‘in good faith’ if patient refuses)
- Doctor will initially make an assessment about their fitness to drive - may require OT assessment
- Usually get 12 month conditional license which means it needs to be reassessed at this time +/- other restrictions i.e. driving at certain limits, certain areas, certain times
What are predisposing factors to developing delirium?
Previous delirium FHx delirium Cognitive impairment Sensory impairment Functional impairment Malnourished, dehydrated, chronic alcohol use Multiple comorbidities Age
What are some causes of delirium?
DIMES
- Drugs - change or withdrawal, specific drugs - benzos, PD meds, NSAIDs, anticholinergics, general anaesthetic, antidepressants, mood stabilisers
- Infection/illness (acute) - UTI or other infection, trauma/surgery, organ failure (hypoxia, electrolyte disturbance, uraemia), cardiac ischaemia
- Metabolic - electrolyte disturbance, abnormal BGLs, acidosis, malnutrition/dehydration
- Environmental factors - iatrogenic (IDC, restraints), disorientating environment
- Symptoms - pain, constipation, incontinence, immobility, sleep disturbance
What are the main diagnostic features of delirium?
- Acute onset (hrs - days)
- Fluctuating conscious state throughout day - drowsy - hyperactive
- Inattention/distractibility
- Disorientation
Other clinical features of delirium?
Sleep disturbance - reversal of sleep-wake cycle, usually worse at night
Disorganised speech & thought
Behavioural & mood issues - wandering, agitated/aggressive, confused, repetitive behaviours
Psychotic features - paranoid delusions and hallucinations
Consequences - falls, incontinence, deterioration of function
What is the natural hx of delirium?
Transient and reversable - usually lasting days-weeks
Can last longer (up to ~1 year) and/or may not return to baseline function - more likely if predisposing factors
Increased risk of mortality, can be early warning sign to serious underlying pathology
What is the best screening tool for delirium?
CAM - confusion assessment method
Highly sensitive and specific for delirium
- Acute onset AND fluctuating course
- Inattention AND
- Disorganised thinking OR altered GSC
Need both 1 and 2 and one of 3 to diagnosis delirium
What are routine Ix and ones to consider in diagnosing delirium?
Routine - O2 sats, U&Es, LFTs, CMP, BGLs, TFTs, urine analysis + MCS, CRP, ESR, FBE
Consider - CT, cardiac ischaemia Ix, septic screen, drug levels (digoxin, lithium)
What are important management principles for delirium?
- Identify and Rx/remove precipitating factors of delirium i.e. pain, constipation, electrolyte imbalance, infection
- Medication review and rationalisation
- Non-pharm Rx - low stimulus, 1:1 nursing, single room, reorientation aids and communication, reduce changes & increase familiarity, avoid restraints & iatrogenic devices
- Actively monitor - behaviour charts, regular physical and visual observations
- Pharm Rx of behaviour - only when really necessary
Haloperidol 1st line. Avoid benzos - worsen delirium
