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Geriatrics > Acute and Chronic Confusion in Old Age > Flashcards

Acute and Chronic Confusion in Old Age Flashcards

1
Q

What might cause confusion in old age?

A 
Deafness
Receptive dysphasia
Expressive dysphasia
Cognitive impairment 
Dysphonia 
Dysarthria
Cultural disharmony
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2
Q

What is cognition?

A

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

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3
Q

What aspects of the history are key when diagnosing the cause of cognitive impairment?

A

Onset - when and how rapid
Course - fluctuating or progressive decline
Associated features e.g. other illness, functional loss

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4
Q

What are the most common causes of cognitive impairment in the elderly?

A

Dementia

Delirium

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5
Q

What are the key features of delirium?

A

Disturbed consciousness - hypoactive, hyperactive or mixed
Change in cognition - memory, perceptual, language, illusions, hallucinations
Acute onset
Fluctuant

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6
Q

What are the other (non-key) features of delirium?

A

Disturbance of sleep-wake cycle
Disturbed psychomotor behaviour
Emotional disturbance
Delusions

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7
Q

Who is affected by delirium?

A

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

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8
Q

What is the incidence of delirium?

A

20-30% of all patients
Up to 50% post-surgery
Up to 85% in last few weeks of life

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9
Q

What is the effect of delirium on morbidity and mortality?

A 
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
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10
Q

What are the possible precipitations of delirium?

A 
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
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11
Q

What are the components of the TIME bundle?

A

T - Think, exclude and treat possible triggers
I - Investigate and intervene to correct underlying causes
M - Management plan
E - Engage and explore

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12
Q

What patients should have a cognitive screen on hospital admission?

A

Everyone over 65

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13
Q

What are the components of the 4AT scoring?

A

Alertness
AMT 4
Attention
Acute change or fluctuating course

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14
Q

What is dementia?

A

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

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15
Q

What are the types of dementia?

A 
Alzheimer's disease
Vascular dementia
Mixed Alzheimer's/vascular
Dementia with Lewy bodies 
Reversible causes
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16
Q

What are the main features of Alzheimer’s disease?

A

Slow, insidious onset
Loss of recent memory first
Progressive functional decline

17
Q

What are the risk factors for Alzheimer’s disease?

A

Age
Vascular risk factors
Genetics

18
Q

What are the features of vascular dementia?

A

Classically step-wise deterioration
Executing dysfunction may predominate
Associated with gait problems
Often have known vascular risk factors - type II diabetes, AF, IHD, PVD

19
Q

What are the features of Dementia with Lewy bodies?

A

Link with Parkinson’s disease - 2/3rd will have movement problems
Often very fluctuant
Hallucinations common
Falls common

20
Q

What are the features of fronto-temporal dementia?

A 
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
21
Q

What are the problems with diagnostic tests for dementia?

A

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

22
Q

What is normally the most important thing for the patient?

A

Whether they can function independently at home

23
Q

What is involved in the treatment of delirium?

A

Treat the cause
Full history and examination
TIME bundle
Pharmacological and non-pharmacological measures

24
Q

What is the pharmacological management of delirium?

A

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)

25
Q

What is the non-pharmacological management of delirium?

A

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

26
Q

What is the non-pharmacological management of dementia?

A 
Support for person and carers
Cognitive stimulation 
Exercise 
Environmental design 
Music/light therapy 
Reality orientation therapy/validation therapy
27
Q

What is the pharmacological management of dementia?

A

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
28
Q

What reversible causes should be considered in dementia?

A 
Hypothyroidism 
Intracerebral bleeds/tumours
B12 deficiency 
Hypercalcaemia 
Normal pressure hydrocephalus 
Always remember depression
29
Q

What else is important in cognitive impairment?

A

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?

Geriatrics (6 decks)

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