care of the elderly Flashcards
what is the CAM (confusion assessment method) based on ICD 10 criteria for diagnosing delirium
- acute onset and fluctuating course
plus - inattention (counting backwards or in interview)
and any of - disorganised thinking
- altered consciousness level (more or less alert)
first line when patient becomes distressed or agitated?
de-escalation methods including
reassurance, increased nursing care including one to one care, eye contact, comforting
LOOK FOR UNDERLYING CAUSE
then haloperidol 0.5mg IM as sedative if the patient is at risk of harming themselves or others
name some general measures for treating an older person with delirium
- reassurance, re-orientation, calm environments
- encourage oral intake of food and drink and record these on the fluid balance charts and food charts
- encourage mobility
- continued AMTS scoring
- follow up in community with regarding dementia (as delirium episodes put one more at risk of developing dementia later on )
- increased nursing observation while in hosp
If a patient is confused and is not responding to de-escalation methods, then what do you do ?
IM 0.5 mg- 1 g Haloperidol . start at a low dose and hopefully they would only need to be on it short term (ideally less than a week)
Olanzapine could be used instead
or lorazepam if these are contraindicated
when is haloperidol contraindicated?
in parkinsons disease and Lewy Body dementia
in this case it would be more appropriate to use LORAZEPAM
nb remember to ask about alcohol intake as if this is n alcohol withdrawal delirium, first line would be a BDZ such as chlordiazepoxide
what should you do if a patient is not responding to the haloperidol and is still delirious>
- re-evaluate for possible causes of delirium
- consider follow up/assessment for dementia
how many patients on medical wards suffer an episode of delirium?
30%
define delirium
delirium is an acute onset of disturbed consciousness (characterised by hypo or hyperalertness), cognitive impairment or impairment of perception , with a fluctuating course
it usually comes on over the period of a couple of days
features of hypoactive delirium
- increased sleeping
- quiet and withdrawn behaviour
- drowsiness
- classic hand movements
features of hyperactive delirium
- agitation
- heightened arousal
- restlessness
- aggression
risk factors for delirium
- over 65 yrs
- current hip fracture
- severe illness
- dementia diagnoses
- sensory impairment
- frailty
precipitants of delirium
- surgery
- drugs
- infection
- urinary retention
- constipation
- pain
good tools for junior doctors to diagnose delirium?
-4AT test or CAM test
score to calculate risk of stroke post TIA
-what factors are taken into account
ABCD2 score a= age >60 b= blood pressure >140/90 c=clinical features of the TIA -unilateral weakness 2 -speech disturbance without weakness 1 d= -diabetes 1 -duration of symptoms >60 min 2 >10 min 1
features of MSA
how is it treated
- parkinsonism
- autonomic signs (atonic bladder, postural hypotension)
- cerebellar signs (ataxia)
treated with levodopa and supportive measures
features of normal pressure hydrocephalus
how is it treated?
gait ataxia
dementia
urinary incontinence
treated with:
diagnostic lumbar puncture
CSF removal
ventriculo-peritoneal shunt
features of vascular parkinsonism
arteriosclerotic, pt may have had a stroke, have vascular risk factors
-may swing arms less than PD
-lower body symptoms : rigidity of lower limbs,
gait ataxia, urinary problems
-memory problems
-tremor is less common,
lack of facial expression
50% respond to levodopa
dementia with lewy body feature
-dementia
-visual hallucinations (prominent)
-parkinsonism
fluctuations in alertness
shared care: psychiatry, neurology, geriatrics
corticobasal degeneration features
dyspraxia asymmetrical parkinson symptoms cortical sensory impairment alien limb phenomenon does not respond well to levodopa
supranuclear palsy features
investigations
treatments
symptoms: impaired vertical gaze early falls truncal rigidity speech disturbance
investigation: MRI scan. midbrain atrophy look for hummingbird sign
treatment
speech and language review and supportive measures
drug induced parkinsonism features
hx dopaminergic blocking drugs eg antipsychotics or metoclopramide
symmetrical parkinson features and rigidity
blank facial expression
features of parkinsons disease
treatments
assymetrical bradykinesia tremor rigidity postural instability
treated with levodopa or dopamine agonists
how would you make a diagnosis of idiopathic parkinsons disease
Bradykinesia PLUS at least one of
- postural instability (not explained better by another cause)
- resting tremor (asymmetrical) 4-6Hz
- muscular rigidity
- exclude other causes
- supporting factors include: (need 3 )
- excellent levodopa response
- levodopa induced chorea
- unilateral onset
- progressive disorder
- progression 10 yrs or more
- levodopa response 5 yrs or more
- continued asymmetry
- rest tremor present
frequency of a parkinsonian tremor
4-6 hz
non motor symptoms of parkinsons disease
olfactory dysfunction cognitive impairment autonomic disturbance (constipation, pain fatigue sleep disturbance low mood swallowing difficulties
Risk factors for pressure ulcers
limited mobility Limited sensation Nutritional deficiency Inability to reposition oneself Terminal illness Chronic illness Smoking Dry skin Old age >70 Cognitive impairment
