Confusion Flashcards
The 6 neurocognitive domains
Complex attention Perceptual motor function Language function Executive function Learning / memory Social cognition
Complex attention is made up of…
Sustained attention
Divide attention
Selective attention
Processing speed
Perceptual motor function is made up of….
Visual perception
Visuo-constructional reasoning
Perceptual motor coordination
Language function is made up of…..
Object naming Word finding Fluency Grammar and syntax Receptive language
Executive function is made up of….
Planning Decision making Working memory Responding to feedback inhibition flexibility
Learning / memory is made up of….
Free recall cued recall recognition memory semantic and autobiolographal long term memory Implicit learning
Social cognition is made up of…..
Recognition of emotions
Theory of mind
Insight
Diagnosing cause of cognitive impairment - things to find out
Onset - when - how rapid Course - fluctuating - progressive decline Associated features - other illness - functional loss e.g. reduced mobility, reduced self care, new incontinence
Subtypes of delirium
Hyperactive
Hypoactive
Mixed
Presentation of delirium
Disturbed consciousness (hypoactive, hyperactive, mixed) Change in cognition - memory / perceptual / language / illusions / hallucinations Acute onset and fluctuant Disturbance of sleep wake cycle Disturbed psychomotor behaviour Emotional disturbance
Precipitants of delirium
Infection (not always UTI) Dehydration Biochemical disturbance Pain drugs constipation/urinary retention hypoxia alcohol / drug withdrawal sleep disturbance brain injury (stroke, tumour, bleed etc) Changes in environment Sometimes no idea and multiple triggers
What is the most common complication of hospitalisation?
Delirium
Who is delirium common in?
50% post surgery
20-30% of all inpatients
up to 85% last weeks of life
Diagnosis of delirium
Alterness AMT4 - age - DOB - place - current year Attention Acute change of fluctuating course
What score of 4AT score indicates possible delirium?
4 or above
What does a score of 1-3 on the 4AT indicate?
Possible cognitive impairment
Treatment of delirium
Treat cause - TIME bundle Pharmacological measures - stop bad drugs (anticholinergics, sedatives) - drug treatment usually not necessary - danger to themselves / cannot be settled = quetiapine orally Re-orientate and reassure patients (use family / carers) Encourage mobility and self care Correction of sensory impairment Normalise sleep wake cycle ensure continuity of care - avoid frequent ward or room transfers Avoid urinary catheterisation/venflons
What is dementia?
Acquired decline in memory and other cognitive functions in an alert person sufficiently severe to cause functional impairment and present for more than 6 months
Types of dementia
Alzheimer's Vascular Mixed Alzheimer's / vascular Dementia with Lewy bodes 'Reversible' causes
Features of Alzheimer’s
Slow insidious onset
loss of recent memory first
progressive functional decline
Risk factors for Alzheimer’s
AGE
vascular risk factors
genetics
What is lost first in Alzheimer’s?
Recent memory
Features of Vascular dementia
Classically step wise deterioration
executive dysfunction may predominate rather than memory impairment
often associated with gait problems
Risk factors for vascular dementia
Vascular RFs
- T2DM
- AD
- IHD
- PVD
Features of dementia with Lewy bodies
May have parkinsonism
Often very fluctuant
Hallucinations common
falls common
Features of fronto-temporal dementia
Onset often earlier age
Early symptoms different from other types of dementia
- behavioural change
- language difficulties
- memory early on not so affected
Usually lack of insight into difficulties
What is key in the diagnosis of Dementia
history
Treatment of dementia
Non-pharmacological - support for family / carers - cognitive stimulation - exercise - avoiding changes in environment / social support etc - advanced care planning - environmental design Pharmacological - cholinesterase inhibitors - anti-psychotics (avoid if possible)
Reversible causes of dementia
Hypothyroidism Intracerebral bleeds/tumours B12 deficiency Hypercalcaemia Normal pressure hydrocephalus Depression
What is always something to remember in the possible reversible causes of dementia?
Depression
What is delirium also known as?
Acute confusional state
Acute organic brain syndrome
What % of elderly are affected of acute confusional state in hospital?
30%
Predisposing factors to acute confusional state
> 65 y/o Background of dementia Significant injury e.g. hip fracture Frailty or multimorbidity Polypharmacy
Precipitating evens for acute confusional state
Infection
Metabolic (hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration)
Change of environment
Any significant CVS, resp, neurological or endocrine condition
Severe pain
Alcohol withdrawal
Constipation
What infection in particular particularly causes acute confusional state?
UTI
Presentation of acute confusional state (variety of presentations)
Memory disturbances (loss of short > long term) Very agitated or withdrawn Disorientation Mood change Visual hallucinations Disturbed sleep cycle Poor attention
Management of acute confusional state
Treat underlying cause
Modification of environment
Haloperidol 0.5mg first line sedative
What does the 4AT look at?
- Alertness
- AMT 4
- Attention
- Acute change or fluctuating course
What is looked at in the alertness section of the 4AT?
Normal (fully alert, non agitated, throughout assessment)
Mild sleepiness for < 10 seconds after waking, then normal
Clearly abnormal
What is looked at in the AMT 4 section of the 4AT?
Age
DOB
Where they are
Current year
What is looked at in the attention section of the 4AT?
Patient is asked to tell the months of the year in backwards order, starting in December.
Achieves 7 months or more correctly
Starts but scores < 7 months / refuses to start
Untestable (cannot start cause unwell / drowsy / inattentive)
What is looked at in the acute change or fluctuating course section of the 4AT?
Evidence of significant change or fluctuation in alertness, cognition, other mental function (e.g. paranoia, hallucinations) over the last 2 weeks and still evident in the last 24 hours
