Confusion Flashcards
What is the best way to determine whether someone is suffering an acute onset confusion or a chronic illness such as dementia?
Speed of onset
Collateral history useful
History of confusion
Previous mental state
3 types of delirium?
Hyperactive - physical and vocal symptoms
Hypoactive - stupor and coma
Mixed - common
4 cardinal symptoms of delirium?
Fluctuating cognitive impairment
Inattention
Disordered thinking
Fluctuation in consciousness
DELIRIUM pneumonic describes what symptoms of delirium?
Disordered thinking Euphoria/anger Language impairment Illusions/delusions Reversal of the sleep wake cycle Inattention Unaware/lack insight Memory deficit
What is the usual time scale to which delirium develops?
over 2-3 days
What are some causes of acute confusion?
(PINCH ME) - pain, infection, nutrition, constipation, hydration, medications, environement
Cerebral blood supply - cardiac conditions
Cerebral metabolism - respiratory, metabolic, nutritional, haematological
Risk factors for developing delirium?
Aged over 65 Recent fall or hip fracture Polypharmacy Visual impairment Infection or dehydration admission Alcohol excess Renal impairment
What is the confusion method diagnostic algorithm (CAM) used for? What 4 features are investigated and how is it done?
Looks into the presence of delirium
4 cardinal features:
Fluctuating condition - ask collateral history
Inattention - count back from 20
Disordered thinking - hallucinations
Fluctuating consciousness - depending if they are hypoactive or hyperactive
7 blood investigations can be done to investigate delirium?
FBC Haematocrit - high in dehydration LFT UE CRP Glucose Calcium
What investigations would you do to investigate delirium?
Bloods CXR ECG Urine dipstick Blood cultures NEWS
What initial management are you interested in correcting for a delirium patient?
Medications review and alteration Correct any electrolyte imbalances that are found Treat infection If they are alcoholic give thiamine Treat constipation
How can you make a good sensory environment for delirium patients?
Good lighting Clocks on the wall One to one care Encourage family and friends to visit Encourage fluid intake Encourage mobility, good diet and fluids to prevent constipation
What antipsychotic is chosen to manage delirium and what dose is initially started at? acutely disturbed?
0.5mg PO Haloperidol every 2 hours if needed
IM Haloperidol 1-2mg for acutely disturbed
What is an alternative drug to treat delirium and what kind of patients is it often used in?
Lorazepam PO 0.5-1mg PO
Used in Parkinson’s patients or dementia with Lewy Body
7 main issues that delirium patients will suffer?
Pressure sores Incontinence Nosocomial infections Falls Functional impairment Over sedation Malnutrition
What is the most common type of dementia? gene that increases likelihood of developing?
Alzheimers
ApoE4
Alzheimers Dementia inheritance pattern? 2 genes it is inherited on?
Autosomal Dominant
APP
presenilin 1 and 2
What is the pathology of Alzheimers dementia both intracellularly and extracellularly?
Where in the brain does Alzheimers start and where does it progress to?
Intracellular tau protein tangles and extracellular amyloid deposits
Starts in the temporal lobe (memory), moves to frontal lobe (behavioural) then to do the rest of the brain and neurone death
Moderate severity Alzheimers presents with what?
Memory difficulties and planning issues
Spreads to speech and visuospatial problems
Vascular dementia 7 risk factors?
IHD, strokes, hypertension, high cholesterol, diabetes, PVD, cigarettes
What is the difference in decline of a patient who has Alzheimers compared to a patient who has Vascular dementia?
Alzheimers = progressive decline Vascular = step wise progression
What type of dementias make up mixed dementia?
Alzheimers and Lewy body
Difference between Lewy body dementia and Parkinsons dementia?
If they present with dementia first then they have lewy body but if the dementia presents more than a year after the parkinsons does then it is known as Parkinsons Dementia
What are Lewy bodies and why do they cause dementia?
They are made of alpha-synuclein and act in brain cells to impair dopamine and Ach binding and therefore action
How does Lewy body dementia present?
Parkinsonian symptoms
Falls
Fluctuations in cognition
REM sleep disorder
What do patients usually die from in Lewy body?
Malnutrition, swallowing difficulties, immobility
Which 2 types of dementia tend to effect people at a younger age?
Lewy body dementia
Frontotemporal dementia
2 diseases that see frontotemporal dementia occuring in them?
Pick’s Disease
Motor Neurone Disease
What happens in frontotemporal dementia?
Degeneration of the frontal and temporal lobes sparing of the others
Protein build up - tau, ubiquitin, FUS inclusions
What tend to be 2 main presenting symptoms in frontotemporal dementia?
Personality changes
Dysphasia
4 things that you must distinguish dementia from?
Mental retardation
Korsakoffs psychosis
Aphasia
Depression
Of those over the age of 65 with a mild cognitive impairment, what percentage will convert into dementia?
10-15% conversion rate
What changes can you expect to see in a person cognitively as they progress with dementia?
Intellectually regress
Behavioural changes
Impaired memory - first recent then older memories
Affective disorders
Focal neuro signs - aphasia, apraxia, apraxia of gait, agnosia
What are memory clinics used for?
Streamlining diagnosis, treatment and follow up of dementia
Planning for the future
Access clinical trial
Non-pharmacological interventions in place for patients with Dementia?
Education
Support services - community dementia team, community services
Cognitive rehabilitation and training
Cognitive stimulation therapy - group setting
Movement programmes
Reminiscence
Group of drugs that are used in treatment of dementia?
Cholinesterase inhibitors
How do you increase the dose of Dementia medication? When does it reach its most effectiveness? how long after diagnosis and treatment initiation do you need to have follow up appointment?
Titrate over 1 month
Reaches effectiveness after 3 months
Follow up after 4 months
3 examples of cholinesterase inhibitors used in mild/moderate Dementia treatment?
Donepezil
Rivastagmine
Galantamine
Main 3 side effects of cholinesterase inhibitors?
Nausea
Vomiting
Diarrhoea
What drug is used in severe dementia? How does it work?
Memantine, antagonising NMDA glutamate receptors
Which type of dementia should you avoid using antipsychotics?
Lewy body/parkinsons dementia
