Acute & chronic confusion in old age Flashcards
What are important features to consider when taking a history of someone with cognitive impairment?
Onset - When and how quickly?
Course - Has the decline be fluctuating or steadily declining
Associated features - Reduced mobility, reduced self-care, new incontinence
What are the commonest causes of cognitive impairment?
Delirium
Dementia
What are the key features of delirium?
1 - Acute onset and fluctuant
2 - Change in cognition
3 - Disturbed consciousness
Apart from the key features, what are some of the other common features of delirium?
1 - Disturbed sleep wake cycle
2 - Disturbed psychomotor behaviour
3 - Emotional disturbance
What are the subtypes of delirium?
Hyperactive
Hypoactive
What changes in cognition can someone with delirium display?
Memory
Perceptual
Language
Hallucinations
Illusions
What can precipitate delirium?
1 - Infection
2 - Dehydration
3 - Drugs
4 - Alcohol withdrawal
How is delirium diagnosed?
4AT score
What questions might you ask a patient you suspect of having delirium or cognitive impairment?
- What is your name and address?
- What is your age? D.O.B? Where are you? Current year?
- Tell me the months of the year backwards
What are the non-pharmacological treatments for delirium?
1 - Re-orientate and re-assure
2 - Encourage early mobility
3 - Normalise sleep-wake cycle
When delirium has been diagnosed which drugs should be stopped?
1 - Anticholinergics
2 - Sedatives
Which drug can be used to treat delirium where the patient is a danger to themselves or extreme distress?
Quetiapine
What is the definition of dementia?
Decline in cognitive functions that are sufficient to cause functional impairment and are present for > 6 months
What are some common signs of dementia?
1 - Forgetting to take tablets
2 - Unable to use phone
3 - Difficulty washing/dressing
What are the 3 main types of dementia?
Alzheimers
Vascular
Dementia with Lewy bodies
What are the characteristic features of alzheimers?
1 - Slow, insidious onset
2 - Loss of recent memories first
3 - Progressive functional decline
What are the risk factors for alzheimers?
1 - Age
2 - Vascular risk factors
3 - Genetics
What are the common features of vascular dementia?
1 - Step-wise deterioration
2 - Executive dysfunction
3 - Gait problems
What vascular risk factors are often present in patients with vascular dementia?
Type 2 DM
AF
IHD
What are the common features of dementia with lewy bodies?
1 - Parkinsonism
2 - Fluctuant
3 - Hallucinations
4 - Falls
What are the common features of a fronto-temporal dementia?
1 - Early age onset
2 - Behavioural change
3 - Language difficulties
4 - Lack of insight
What are some methods used to diagnose dementia?
MMSE
MOCA
What are some non-pharmacological treatment options for dementia?
1 - Cognitive stimulation
2 - Exercise
3 - Avoid changes in environment
What pharmacological treatments can be used for dementia?
Cholinesterase inhibitors
82 year old man
Brought to A&E as found walking down street with his pyjamas on
D/w family
Increasingly forgetful over last year
Burns pans
Frequent phone calls to daughter
Accusing carers of stealing
Gradual decline over last 2 years
No significant PMH
Bloods - normal
What is the diagnosis?
Alzheimers
89 years old
Normally lives independently
“off legs, confused”
Febrile, “smells of urine”, looks dry
DH
Aspirin, furosemide, ramipril, codydramol, amitriptyline
Normally independent
Still travelling the world
No memory problems
Fall and subsequent sore knee recently
GP started a new tablet
Bloods
CRP 15, WCC 8
Urea 12, creat 65
What is the diagnosis?
Delirium
Very old man
Lives alone in isolated house
No family
Fall with long lie
PMH: BPH, hypertension, AF
Drugs: Codydramol, Thyroxine, tamsulosin, Omeprazole, Metoclopramide, Ramipril, amlodipine
–Not right for a year
–Good days and bad days
–Shouting at people who aren’t there
–Lots of falls
–Slowed down last few months
What is the diagnosis?
Dementia with Lewy bodies
