Acute and Chronic Confusion in Old Age Flashcards
What might cause confusion in old age?
Deafness Receptive dysphasia Expressive dysphasia Cognitive impairment Dysphonia Dysarthria Cultural disharmony
What is cognition?
The mental action or process of acquiring knowledge and understanding through thought, experience and the senses
Much more than just memory - sequencing, planning, problem solving, visuospatial, speech
What aspects of the history are key when diagnosing the cause of cognitive impairment?
Onset - when and how rapid
Course - fluctuating or progressive decline
Associated features e.g. other illness, functional loss
What are the most common causes of cognitive impairment in the elderly?
Dementia
Delirium
What are the key features of delirium?
Disturbed consciousness - hypoactive, hyperactive or mixed
Change in cognition - memory, perceptual, language, illusions, hallucinations
Acute onset
Fluctuant
What are the other (non-key) features of delirium?
Disturbance of sleep-wake cycle
Disturbed psychomotor behaviour
Emotional disturbance
Delusions
Who is affected by delirium?
Delirium can affect anyone but it is more associated with the extremes of age due to the reduction in homeostatic physiological ability in these age groups
Should therefore be taken very seriously in individuals who are not frail
What is the incidence of delirium?
20-30% of all patients
Up to 50% post-surgery
Up to 85% in last few weeks of life
What is the effect of delirium on morbidity and mortality?
Increased risk of death Longer length of stay Increased rates of institutionalisation Persistent functional decline Many people have a residual cognitive impairment, and a proportion of people will have delirium that does not resolve
What are the possible precipitations of delirium?
Infection (NOT always a UTI!!!) Dehydration Biochemical disturbance Pain Drugs Constipation/urinary retention Hypoxia Alcohol or drug withdrawal Sleep disturbance Brain injury Sometimes no clear cause, may be multiple triggers
What are the components of the TIME bundle?
T - Think, exclude and treat possible triggers
I - Investigate and intervene to correct underlying causes
M - Management plan
E - Engage and explore
What patients should have a cognitive screen on hospital admission?
Everyone over 65
What are the components of the 4AT scoring?
Alertness
AMT 4
Attention
Acute change or fluctuating course
What is dementia?
An acquired functional decline in memory and other cognitive functions in an alert person, sufficiently severe to cause functional impairment and present for more than 6 months
e. g.
- forgetting to take tablets
- unable to sue phone
- difficulty washing/dressing
What are the types of dementia?
Alzheimer's disease Vascular dementia Mixed Alzheimer's/vascular Dementia with Lewy bodies Reversible causes
What are the main features of Alzheimer’s disease?
Slow, insidious onset
Loss of recent memory first
Progressive functional decline
What are the risk factors for Alzheimer’s disease?
Age
Vascular risk factors
Genetics
What are the features of vascular dementia?
Classically step-wise deterioration
Executing dysfunction may predominate
Associated with gait problems
Often have known vascular risk factors - type II diabetes, AF, IHD, PVD
What are the features of Dementia with Lewy bodies?
Link with Parkinson’s disease - 2/3rd will have movement problems
Often very fluctuant
Hallucinations common
Falls common
What are the features of fronto-temporal dementia?
Onset often at an earlier age Early symptoms different from other types of dementia - behavioural changes - language difficulties - memory early on is often not affected Usually lack insight into difficulties
What are the problems with diagnostic tests for dementia?
Can be culturally/generationally/intellectually specific
Can be falsely reassuring - should be used as screening and monitoring tools, not only as a means of diagnosis
What is normally the most important thing for the patient?
Whether they can function independently at home
What is involved in the treatment of delirium?
Treat the cause
Full history and examination
TIME bundle
Pharmacological and non-pharmacological measures
What is the pharmacological management of delirium?
Most drugs are bad
Stop any causative drugs e.g. anticholinergics, opiates (unless patient is in pain) and sedatives (unless patient has been on them long-term)
Drug treatment of delirium is usually not necessary
Drugs only indicated if patient is a danger to themselves or others, or in distress which cannot be settled in any other way
12.5mg quetiapine (start low dose and work up slowly if needed)
What is the non-pharmacological management of delirium?
Re-orientate and reassure agitated patients, may need to use families/carers
Encourage early mobility and self-care
Correction of sensory impairment
Normalise sleep-wake cycle
Ensure continuity of care - avoid frequent ward or room transfers
Avoid urinary catheterisation/venflons
What is the non-pharmacological management of dementia?
Support for person and carers Cognitive stimulation Exercise Environmental design Music/light therapy Reality orientation therapy/validation therapy
What is the pharmacological management of dementia?
Cholinesterase inhibitors
- mainly used in Alzheimer’s
- Galantamine licensed in mixed dementia
- Rivastigmine in dementia with Lewy bodies
- maximum 2-3 point improvement in MMSE but may delay institutionalisation
Anti-psychotics
- avoid if possible
- increased risk of cardiovascular death
- start low and go slow
What reversible causes should be considered in dementia?
Hypothyroidism Intracerebral bleeds/tumours B12 deficiency Hypercalcaemia Normal pressure hydrocephalus Always remember depression
What else is important in cognitive impairment?
Capacity
- is the patient able to make decisions about their care?
- do they have a legally appointed proxy decision maker?
- do medical staff/relatives know what their wishes would be regarding care?
