COE Flashcards
Define delirium?
acute confusional state with fluctuating levels of consciousness
Define dementia
global decline in cognition and has progressive course with no changes in the level of conciousness
What are the different kinds of delirium?
hyperactive
hypoactive
mixed
How would hyperactive delirium present?
heightened arousal (sensitive to surroundings, verbally and physically threatening and aggressive, restless)
Repeated pulling at clothing (carphologia)
Wandering and disorientated
Unable to follow complex commands
How would you hypoactive delirium present?
decrease in psychomotor activity
*usually diagnosed as depression
What are some risk factors for delirium?
Increased age
dementia
polypharmacy
alcohol excess
environmental factors
What are some causes of delirium?
DELIRIUM
Drugs
Electrolyte and physiological abnormality
Lack of drug (withdrawal)
Infection
Reduced sensory input (blind, deaf, changed environment)
Intracranial problems (stroke, post-ictal, meningitis, subdural haemorrhage)
Urinary retention and faecal impaction
Myocardial (MI, arrhythmia, HF)
What drugs can cause delirium?
BAD HAT
Benzos - lorazepam
Analgesic - codeine
Diuretic - furosemide
anti-Histamines - chlorphenamine, hydroxyzine
anti-Arrhythmic - digoxin
TCA - amitriptyline
What are the differences between delirium and dementia?
Dementia
chronic progressive (delirium is flunctuating) preserved atten conscious irreversible no underlying medical cause
What tools could you use to assess someone with suspected Delirium?
AMT (abbreviated mental test)
MMSE
What questions to use in AMT?
How old are ya?
What is your D.O.B.?
What is this place?
What year is it?
<4 = some cognitive impairment
What are the components of the MMSE?
Orientation
Registration
Attention and Calculation
Recall
Language
What are some non medical ways of managing delirium?
soft lighting
clocks and calendars
sleep hygiene
avoiding constant change of environment
minimize provocation
What is recommended sedative in management of delirium?
Haloperidol and Olanzapine
What is a comprehensive geriatric assessment?
Identifies health problems and establishes management plans in older patients w/ frailty
What are the aspects of the comprehensive geriatric assessment?
Medical Assessment - Problem list (diagnosis and treatment), co-morbid conditions & disease severity, Medication review- doctor / consultant
Functional Assessment - ADL, gait, balance- occupational therapist, physiotherapist
Psychological Assessment - cognition, mood- nurse, psychiatrist
Social assessment - care resources, finances- social worker
Environmental assessment - home safety
Who are the professionals involved in a comprehensive geriatric assessment?
Geriatrician
Social Worker
Physiotherapist
Occupational Therapy
What are the features of Alzheimer’s dementia?
Memory Impairment
Language Impairment
Visuo-spacial
Behavioural
Psychiatric
What are the treatments for Alzheimer’s?
Donepezil
Rivastigmine
for add-on, severe or if others not tolerated
Memantine
What are some non-medical methods of Alzheimer’s disease?
activities to promote wellbeing that are tailored to the person’s preference
group cognitive stimulation therapy for patients with mild and moderate dementia
group reminiscence therapy and cognitive rehabilitation
What are the features of cerebrovascular dementia?
stepwise progression in patient with vascular disease, which may manifest as repeated strokes
What are the features of Fronto-temporal/Pick disease?
Atrophy of frontal or anterior temporal lobes
Onset before 65
Frontal - personality, social behaviour, disinhibition
Temporal - progressive aphasia
Preserved memory and Visuospatial skills
What is the pathology behind Lewy-Body dementia?
alpha-synuclein cytoplasmic inclusions in substantia nigra, paralimbic and neocortical areas
What are the features of Lewy-Body dementia?
Progressive cognitive impairment, parkinsonism, visual hallucination
How would you manage Lewy-Body dementia?
acetyl-cholinesterase inhibitors
Donepezil, Rivastigmine
What are the 5A’s of Alzheimer’s?
Amnesia Aphasia Apraxia Agnosia Apathy
What are some examples of cognitive assessment tools?
Addenbrookes cognitive examination-III (ACE-III)
Montreal cognitive assessment (MoCA)
Abbreviated mental test score (AMT)
6-Item cognitive impairment test (6CIT)
General practitioner assessment of cognition (GPCOG)
What is mild cognitive impairment?
Cognitive impairment but minimal impairment of ADL’s
What is the delirium screen?
FBC (WCC for infection, anaemia, MCV) U&Es (urea, AKI or Na+, K+) LFT (liver failure, or alcohol abuse) blood glucose TFTs (hypothyroid) ↑Ca2+ (bones stones, groans, psychic moans) haematinics (B12 and folate) INR (Warfarin, bleeding risk) Septic Screen urine dipstick chest X-ray blood cultures
ECG Malaria films Lumbar Puncture EEG CT / MRI
What is osteoporosis?
Loss of bone mass
Presence of BMD of 2.5 SD below mean
What are some risk factors for osteoporosis?
SHATTERED
Steroids
Hyperthyroid, Hyperparathyroid and Hypocalcaemia
Alcohol/Tobacco
Testosterone
Thin
Erosion (IBD)
Renal/ Liver Failure
Early Menopause
Diet
What tool can you use to assess osteoporosis risk? What does it measure?
FRAX - 10 yr risk of fragility fracture
How would you treat Osteoporosis?
Vit D + Calcium supplementation
Alendronate
Strontium Ranelate
What is common side effect of alendronate? What can be offered as an alternative?
GI problems
risedronate and etidronate
What are some causes of Falls/Collapse?
DAME
Drugs (diuretics, alpha blockers, beta blockers, levo-dopa, sildenafil and including alcohol)
Age-related (gait, balance probs, muscle weakness and sensory impairment)
Medical (CVD, Heart disease, Parkinson’s)
Environmental (obstacles, lighting)
vision probs, peripheral neuropathy, orthostatic hypotension and polypharmacy
dementia, delirium, depression
What are some physical consequences of falls/collapse?
Soft tissue bruising
Breaks in skin
Fractures
Friction burn
What are some psychological consequences of falls/collapse?
Fear of falling > immobility
Loss of confidence
Anxiety
Depression
What can be done as management following a fall/collapse?
PT - walking aids, improve gait, teach how to get up
OT - remove hazards, equipment (chair lift)
Challenge all medication
Appropriate footwear
What are some complications of incontinence?
Embarassment > fear of going out > social isolation
Depression
Sexual Problems
Skin irritation > pressure sores
What are the causes of incontinence?
DIAPERS
Delirium
Infection
Atrophic Urethritis
Pharma - sedatives, coffee, AD, alco
Excess urine production - diabetes
Restricted mobility - physio, walking aids, commode
Stool Impaction - laxatives, fluid intake
What are the different types of incontinence?
Stress Incontinence
Urge Incontinence
Overflow Incontinence
What causes stress incontinence? Who is it commonly seen in?
Sneezing, Coughing, Exercise
Common in multiparous women
Common after radical prostatectomy
What is the treatment for stress incontinence?
Pelvic floor exercise (8 contractions, 3x a day for 3 months)
Ring Pessaries
Duloxetine
Surgery
What is urge incontinence? Who is it commonly seen in?
Frequent and urgent passing of small amounts - not enough time to reach toilet
Stroke, MS, Parkinson’s
How would you treat urge incontinence?
Oxybutynin and tolterodine
When do you get overflow incontinence?
BPH and Diabetes
How would you investigate incontinence?
Bladder Diary for 3 days
Vaginal exam - check kegels
Urine dipstick and Culture
differences in depression and dementia?
Depression is global memory problems short term and long term
Depression would be more acute symptoms
Factors suggesting diagnosis of depression over dementia
short history, rapid onset
biological symptoms e.g. weight loss, sleep disturbance
patient worried about poor memory
reluctant to take tests, disappointed with results
mini-mental test score: variable
global memory loss (dementia characteristically causes recent memory loss)
What medications can cause postural hypotension?
Diuretics
ACE -I
Beta Blockers
Alpha-blockers
What medication can help postural hypotension?
fludrocortisone
What are pressure ulcers? What are somethings that could make them worse?
Pressure sores are areas of necrosis due to persistent and unrelieved pressure that exceeds the perfusion pressure of the tissues
Shearing forces aggravate the problem
Moisture (incontinence) causes maceration of the skin which worsens damage
What are some risk factors for pressure ulcers?
increasing age (reduced skin strength and elasticity)
reduced mobility
impaired level of consciousness
sensory neuropathy (diabetes, alcohol)
terminal illness
incontinence
low BMI
poor nutrition/hydration
peripheral vasc disease
delirium/dementia
poor skin hygience
previous pressure damage
sedatives
What are common sites for pressure ulcers?
Ischial tuberosity
Sacrum
Greater trochanter
Heels
Occiput
What is the ulcer prevention/treatment policy called? What are its main headings?
Waterlow
BMI
Skin type/visual risk aread
Malnutrition screening tool
continence
mobility
SPECIAL RISKS (tissue malnutrition, neurological deficit, major surgery/trauma)
How to prevent pressure ulcers?
reduce immobility
regular turning
pressure relieving mattresses
protect vulnerable areas
position (on wheel chair etc)
minimize sedation
nutrition
maintain perfusion (BP and hydration)
keep skin dry
What can be used to grade ulcers? What is the grading?
European Pressure Ulcer Grading
1 - non blanchable erythema
2- ulcer superficial and presents as abrasion or blister
3 - full thickness skin loss - damage to or necrosis of subcut tissue
4 - extensive destruction, to muscle bone or supporting structures, with or without full skin loss
When is a pressure ulcer considered a clinical incident?
grade 2 and above
What investigations for ulcer?
FBC - anaemia
albumin - low level will delay healing
blood glucose
wound swab and culture
blood culture
XR - osteomyelitis
Management of pressure ulcer?
NURSE/ DOCTOR - identify at risk
vitamins, vasodilators
good nutrition
fluid balance
pain relief
PHYSIO - turning and positioning
OT - home - cushions, hoists, clothing
PHARMACIST - dressings (transparent adhesive, hydrocolloid, gel dressings, calcium alginate, charcoal dressings)
DIETICIAN - nutritional intake
debridement
abx
Below what MMSE score would a patient be said to have dementia?
repeatedly below 23/30
