Ch15: Gerontology Flashcards
etiology of delirium
typically precipitated by an acute underlying illness
some underlying cause
onset of delirium
sudden state of rapid changes in cognition or mental status, over hours to days
memory loss in dementia most commonly affects [proximal vs. distant] events
loss of memory for recent, proximal events
“sundowning” or progressive worsening as the day progresses: delirium or dementia
delirium
expected change in psychomotor activity in delirium
- 25% hyperkinetic/ hyperactive
- 25% hypoactive
- 35% mixed
- 15% no change
delirium or dementia: speech content is incoherent, confused, with a wide variety of often inappropriately-used words such as misnamed persons or items
delirium
delirium or dementia: in earlier stages, marked by word-searching and progressing to sparse speech content. may be mute in later disease
dementia
delirium or dementia: marked perceptual disturbances, including hallucinations
delirium
no perceptual disturbances in dementia until later on in the disease
DELIRIUMS mnemonic for causes of delirium
D - drugs E - emotional or electrolyte disturbance L - low oxygen, lack of drugs I - infection R - retention (urinary or fecal), reduced sensory input I - ictal or post-ictal state U - undernutrition M - metabolic or myocardial problems S - subdural hematoma
most common electrolyte disturbance in older adults
hyponatremia
aging kidneys tend to waste sodium and hang on to potassium
also, we prescribe a lot of salt-depleting drugs to older adults like diuretics
problematic drugs in older adults that can cause delirium
- TCAs (anticholinergic effects)
- 1st gen antihistamines, e.g., diphenhydramine (anticholinergic effects)
- doxepin (anticholinergic effects; used for anx/dep)
- OAB medications e.g., oxybutynin (anticholinergic effects)
- 1st and 2nd gen antipsychotics
- opioids/opiates
- benzodiazepines
- alcohol
most common cause of delirium in elderly adults (2)
INFECTION
- UTI (MOST common)
- CAP pneumonia (distant second)
how does an older adult present with UTI (2)
- new onset AMS/confusion
- new onset wetting/incontinence
delirium s/t hypoxemia can occur in these (4) conditions
- CAP pneumonia
- COPD exacerbation
- MI
- PE
reduced sensory input examples that can cause delirium in elderly adults
- loss of eyeglasses
- loss of hearing aids
- hearing loss
(4) nutrition issues in elderly adult that can contribute to delirium
- dehydration
- protein/calorie malnutrition
- vitamin B12 deficiency
- folate deficiency
new onset confusion and new onset SOB in elderly adult, consider this on your differential….
myocardial infarction
subdural hematomas can be a result of even minor head trauma for older adults, due to a combination of (2)
- brain atrophy
- fragile blood vessels
most common (2) causes of delirium in elderly adults (generally)
- infections
2. medications
% of dementias that are Alzheimer-type
50-80%
% of dementias that are vascular (multi-infarct) dementia
20%
% of dementias that are Parkinson’s disease
5%
approximately 30% of people with Alzheimer-type dementia also have …..
vascular dementia
rare dementia type marked by intense hallucinations and behavior change
Lewy Body dementia
lab tests in evaluation of the person with new onset altered mental status
DEFINITELY:
- URINALYSIS with urine culture & sensitivity (most important one)
- CMP (electrolytes [especially Na and Ca] and kidney function, liver function)
- serum glucose
- serum vitamin B12
- serum folate
- TSH
- CBC with WBC differential
- ECG (could reveal ACS)
- RPR/VDRL syphilis testing (r/o neurosyphilis)
BY RISK FACTORS:
- brain imaging (CT vs. MRI; particularly useful if there was a head injury)
- toxic screen (concern for substance use)
- chest xray (if RR is up, suspected pneumonia)
- ESR (inflammation)
- HIV
(4) medications that can be considered to slow the decline mild-moderate (early) Alzheimer’s dementia
- cholinesterase inhibitors (eg., donepezil [Aricept], rivastigmine [Exelon], galantamine [Razadyne] have a clear though minor and time-limited benefit by increasing availability of acetylcholine
- memantine (Namenda), an NMDA receptor antagonist that exerts effect on glutamate, helpful in combination with cholinesterase inhibitor
- vitamin E 1,000 IU BID
- selegiline 5mg BID (no added benefit to using selegiline AND vitamin E, just choose one)
medication class: donepezil (Aricept)
cholinesterase inhibitors –> increase availability of acetylcholine
medication class: rivastigmine (Exelon)
cholinesterase inhibitors –> increase availability of acetylcholine
medication class: galantamine (Razadyne)
cholinesterase inhibitors –> increase availability of acetylcholine
why are the benefits of cholinesterase inhibitors time-limited in the treatment of dementia?
because they require live neurons to work on and sadly there is neuronal loss as dementia progresses?
preferred SSRI (1) for elderly adults with dementia and depression (2)
- escitalopram (Lexapro)
lowest potential for drug-drug interactions
% of folks with dementia who also have depression
40%