CCSMH Assessment and Treatment of Delirium + CCSMH LTC Homes paper

Question 1

is general anesthesia associated with increased post operative delirium

Answer 1

no–> not with post op delirium but yes with post op cognitive dysfunction

Question 2

what medication has been shown to reduce incidence of delirium in older patients admitted to acute medical unit

Answer 2

melatonin–> short term, low dorse

more research needed

Question 3

what medication seems to reduce incidence and/or severity of post op delirium in older patients

Answer 3

haldol (short term, low dose)

Question 4

what medication seems to reduce the risk of post op delirium in those without contraindications after cardiac suergery

Answer 4

risperidone

Question 5

is olanzapine recommended for prevention of post op delirium

Answer 5

no–> may reduce risk but if delirium DOES occur is seems to be worse and lasts longer

Question 6

what is one way to reduce risk of delirium in mechanically ventilated patients

Answer 6

choose DEXMEDETOMEDINE as the sedative rather than benzos and propofol

Question 7

are high or low potency antipsychotics preferred in management of delirium

Answer 7

high potency

Question 8

what is the antipsychotic of choice in the management of delirium

Answer 8

haldol

Question 9

in which cases is haldol not recommended

Answer 9

if preexisting parkinson disease or LBD

Question 10

are cholinesterase inhibitor recommended for the prevention or treatment of delirium

Answer 10

no

Question 11

how should you treat older adults with severe MDD in LTC homes? what about less severe depression?

Answer 11

severe MDD–> antidepressant included int reatment

less severe–> psychosocial interventions as first step –> if depression persists then consider antidepressant

Question 12

what are appropriate first line antidepressants for LTC home residents

Answer 12

SSRIs (i.e citalopram, escitalopram, sertraline)

venlafaxine

mirtazapine

buproprion

duloxetine

Question 13

social contact interventions can help manage what symptoms in LTC residents wiht dementia

Answer 13

behavioural symptoms

Question 14

what interventions, in the domain of sensory stimulation, have increased evidence for LTC residents with dementia

Answer 14

music therapy

acupressure

therapeutic touch

Question 15

what doses are generally considered more appropriate for citalopram and escitalopram in older adults

Answer 15

citalopram–> 20mg

escitalopram–> 10mg

*due to concern about QTc prolongation

Question 16

what medication might be used to treat apathy associated with alzheimer’s disease

Answer 16

psychostimulants like methylphenidate

Question 17

what two steps should be taken before using medications to manage behavioural symptoms in LTC residents

Answer 17

1. rule out underlying medical problem *i,e delirium, pain, drug toxicity
2. use psychosocial interventions

Question 18

what class of medications has the best evidence for pharmacological intervention of aggression and psychosis in LTC residents

Answer 18

antipsychotics

Question 19

what is the concern about use of antipsychotics in older adults

Answer 19

increased rates of death and cerebrovascular events as well as other adverse events

Question 20

when should antipsychotics be used in older adults

Answer 20

only if marked risk, disability or suffering associated with symptoms

Question 21

other than antipsychotics, what other class of meds (and which two meds in particular) has some evidence for reducing agitation associated with dementia

Answer 21

SSRIs–> citalopram and sertraline

*may want to try these first and then go for an AP
*remember risk of falls even at low doses of SSRIs in those with dementia

Question 22

do cholinesterase inhibitors have good evidence for treating behavioural symptoms

Answer 22

weak evidence

*evidence is also weak for memantine

Question 23

despite weak evidence for treatment of behavioural symptoms in LTC residents, in what way might memantine still be useful for behavioural symptoms of dementia

Answer 23

mayyyyy delay emergence of behavioural symptoms in those with dementia

Question 24

what population is especially at high risk for suicide

Answer 24

older men (can be up to twice that of the nation as a whole)

Question 25

what were the two most common means of suicide among older men in canada

Answer 25

hanging firearm use

Question 26

what were the two most common means of suicide in older women

Answer 26

hanging self poisoning

Question 27

how does lethality of self harm behaviour change with age

Answer 27

increases with advancing age

Question 28

how might older adults present with depression

Answer 28

less likely to present with dysphoria more likely to present with SOMATIC SYMPTOMS

Question 29

what types of disorders elevate risk for suicide in older adults

Answer 29

mood substance psychotic +multiple comorbid disorders increases risk

Question 30

is dementia a risk factor for suicide

Answer 30

"dementia MAY BE a risk factor but thus has NOT BEEN CLEARLY DEMONSTRATED" (page 22/40 in the 2006 guidelines)

Question 31

how does functional impairment impact the risk for suicide in older adults

Answer 31

impairment of ability to carry out ADLs may increase risk of suicide amongst older adults

Question 32

list medical illness risk factors for suicide in older adults

Answer 32

visual impairment malignancy neuro disorder chronic lung disease seizure disorder moderate or severe pain cancer COPD in married adults 55 and older

Question 33

list 3 measures designed to assess suicidal features in older adults

Answer 33

harmful behaviours scale reasons for living scale--older adults version geriatric suicide ideation scale

Question 34

should you do amyloid imaging if there is no memory loss

Answer 34

no

Question 35

what is the definition of rapidly progressive dementia

Answer 35

develops within 12 MONTHS of first cognitive symptoms or, in AD, if MMSE declines more than 3 points in 6 months

Question 36

list indications for CT scans in the context of suspected dementia/cognitive impairmment

Answer 36

AGE BELOW 60 GAIT DISTURBANCE rapid, unexplained decline (within 1-2 months) short duration of dementia (less than 2 years) recent, significant head trauma unexplained neuro sx i.e headache, seizure new focal neuro signs unusual/atypical cognitive symptoms or presentation hx cancer use of anticoagulants hx bleeding disorder hx urinary incontinence and gait disorder (rule out NPH)

Question 37

which scan is recommended first--18F-FDG PET or SPECT rCBF

Answer 37

PET first but if not avail then do SPECT

Question 38

is fMRI recommended at this time for investigating cognitive complaints

Answer 38

no

Question 39

in what context would you do PET amyloid imaging

Answer 39

as adjunct for complex, atypical presentation *NOT for routine/investigation etc, only for research or above

Question 40

is MR spectroscopy useful

Answer 40

not yet--> may be promising in the future for predicting conversion of MCI to dementia but needs more research

Question 41

how do you manage dementia

Answer 41

symptomatically--> base management on predominant cause as most cases are mixed etiology

Question 42

list the 3 cases in which cholinesterase inhibitors are recommended

Answer 42

1. mild-severe alzheimers disease (all 3 cholinesterase inhibitors) 2. AD + cerebrovascular disease 3. parkinsons disease dementia

Question 43

is there any efficacy difference between the cholinesterase inhibitors

Answer 43

no--> base selection on SE profile, ease of use, familiarity etc

Question 44

is the combination of cholinesterase inhibitors + memantine recommended?

Answer 44

insufficient evidence to recommend BUT appears rational and safe

Question 45

list 3 medications recommended for severe agitation, aggression and psychosis associated with dementia

Answer 45

risperidone olanzapine abilify *valproate, cholinesterase inhibitors, memantine NOT recommended *insufficient evidence for quetiapine, SSRI, trazodone for this

Question 46

when are antidepressants recommended in dementia

Answer 46

for depressive disorders that are non responsive to nonpharm tx