Cognition, delerium and dementia

Question 1

What is delirium?

Answer 1

An acute state of impaired cognition that is usually caused by acute illness.

Question 2

What test should be used for delirium?

Answer 2

The 4 AT test
Alertness - ask name and address
AMT4
Attention - months of year backwards
Acute change - in last 2 weeks, still evident

Question 3

What are the components of the AMT4 test?

Answer 3

Age
Date of birth
Place (e.g. hospital)
Current year

Question 4

What are the components of the abbreviated mental test score (AMTS)? what is the cut off?

Answer 4

Time of day
Place
Date of birth
Year
Address
Age
Identify two people
Name of monach
Date of start of first world war
Count backwards from 20-1
If scores less than 7 then indicates possible dementia

Question 5

What are the two most common causes of delirium?

Answer 5

Infection 
Surgery (delirium is most common post surgical complication in the elderly)

Question 6

What is the key cognitive deficit in delirium?

Answer 6

Attention

Question 7

How should delirium be managed?

Answer 7

Important to recognise and treat the underlying cause

Comprehensive examination of relevant systems

Question 8

When would a delirium patient be given sedation and what would be used?

Answer 8

Can be used if the patient is at risk to themselves or others or is severely distressed.
Haloperidol 0.5mg orally and titrate up to 5mg to relieve symptoms
Lorazepam 0.5mg in parkinsons
Benzodiazepines good for alcohol withdrawl

Question 9

What are the causes of dementia?

Answer 9

Alzheimer’s - most common cause (50%)
Vascular dementia (20%)
Lewy body dementia (20%)

Question 10

What are the features of Alzheimer’s disease?

Answer 10

Insidious onset with impaired short term memory and cognitive function decline. Diagnosis made on clinical features.

Question 11

What are the features of vascular dementia?

Answer 11

Stepwise decline with sudden intellectual decline followed by period of improvement.

Question 12

What are the characteristics of lewy body dementia?

Answer 12

Characterised by fluctuations in mental state, hallucinations and often falls

Question 13

How do you diagnose dementia?

Answer 13

Using history and tools such as the informant questionaire of cognitive decline (IQCODE)
Neuroimaging can be used to differentiate mimics such as space occupying lesions

Question 14

How do you manage dementia?

Answer 14

Some people benefit from donepezil and rivastigmine(acetylcholinesterase inhibitors) and memantine (NMDA antagonist) also has a role as second line

Question 15

What parts of cognition does clock drawing help assess?

Answer 15

It helps assess executive functioning (paying attention, planning), frontal lobe and visuospatial ability

Question 16

What test can be used to assess depression in the elderly? what values are significant?

Answer 16

Geriatric depression scale

15 questions - 5-10 is mild depression >10 is severe depression

Question 17

How does onset differ between dementia and delirium?

Answer 17

Acute onset in delirium, slow onset in depression

Question 18

How does the fluctuation of cognition differ between delirium and dementia?

Answer 18

High fluctuation in delirium and low in dementia

Question 19

How does attention differ between dementia and delirium?

Answer 19

Poor attention in delirium, often good in dementia

Question 20

How does conscious level differ between delirium and dementia?

Answer 20

It is often reduced in delirium and normal in dementia

Question 21

How does emotional instability differ between delirium and dementia?

Answer 21

In delirium there is high emotional instability, in dementia it is only present in later stages

Question 22

How does sleep differ between delirium and dementia?

Answer 22

In delirium sleep is disturbed whereas it is usually normal in dementia

Question 23

How do short term and long term memory differ in delirium and dementia?

Answer 23

In delirium both are poor in dementia long term memory is often good

Question 24

What MRI features would be present in Alzheimer’s?

Answer 24

Cortex atrophy, ventricular enlargement and severe degeneration of the hippocampus

Question 25

Where are the primary side effects of neuro drugs? What does this require?

Answer 25

They are on the heart so require an ECG before prescribing to make sure no underlying problems

Question 26

What are the causes of delerium?

Answer 26

Infection
Stroke
Metabolic imbalances - hyponatraemia or hypocalcaemia
Severe chronic illness