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Confusion Flashcards

1
Q

What are the difficulties in trying to define confusion

A 
Can be a brain problem
Deafness
Asking someone to do something that is too difficult
Culture differences
Etc
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2
Q

What is it better to think about rather than confusion?

A

Cognition

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3
Q

What are the six neurocognitive domains and subdomains in DSM5?

A 
Complex attention 
Perceptual-motor function
Language function 
Executive function 
Learning/memory
Social cognition
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4
Q

What is involved in complex attention?

A

Sustained attention
Divided attention
Selective attention
Processing speed

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5
Q

What is involved in perceptual-motor function?

A

Visual perception
Visuoconstructional reasoning
Perceptual-motor co-ordination

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6
Q

What is involved in language function?

A 
Object naming
Word finding
Fluency
Grammar and syntax
Receptive language
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7
Q

What is involved in executive function?

A 
Planning
Decision making
Working memory 
Responding to feedback 
Inhibition 
Flexibility
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8
Q

What is involved in learning and memory?

A 
Free recall
Cued recall
Recognition memory 
Semantic and autobiographical long term memory 
Implicit learning
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9
Q

What is involved in social cognition?

A

Recognition of emotions
Theory of mind
Insight

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10
Q

Why is assessing cognition of value?

A

?Relevant to current medical problems
Associated with increased risk of death/increased length of stay/discharge to care home
May need to alter communication/involve family
Decisions re capacity
May alter appropriateness of tests/Ix/Rx
May be able to improve it

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11
Q

What is the reversible cause of confusion?

A

Delirium

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12
Q

What is key in diagnosing cause of the cognitive impaired?

A 
History 
Collateral history (GP, family etc.)
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13
Q

What do you want to know from the history of a confused person?

A

Onset - when, how rapid
Course - fluctuating, progressive decline
Associated features, e.g. other illness or functional loss (e.g. reduced mobility or self-care, new incontinence)

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14
Q

What are the key features of delirium?

A

Disturbance consciousness
Changes in cognition
Acute onset & fluctuant
Generally worse at night

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15
Q

What are the two kinds of delirium?

A

Hyperactive delirium
Hypoactive delirium
Often a mix

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16
Q

What is hyperactive delirium?

A

Restless, exploring environment, agitated

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17
Q

What is hypoactive delirium?

A

Abnormally sleepy
(Lethargic, sedated, stupor)
(sometimes hard to stop)

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18
Q

What are some other common features of delirium?

A

Disturbed sleep wake cycle
Disturbed psychomotor behaviour (more likely to fall)
Emotional disturbance

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19
Q

Who does delirium tend to affect?

A

Those at extremes of age

Those who are frail or have cognitive frailty (e.g. dementia, parkinsons, MS etc.)

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20
Q

Why is the proposed mechanism for delirium?

A

Maladaptive pro-inflammatory response

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21
Q

What are some common precipitants of delirium?

A 
Infection, e.g. UTI 
Dehydration 
Biochemical disturbance 
Pain
Drugs
Constipation/urinary retention 
Hypoxia
Alcohol/drug withdrawal 
Sleep disturbance 
Brain injury, e.g. stroke, tumour, bleed
Changes in environment and social set up 
Often multiple triggers
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22
Q

What kind of changes in cognition can occur with delirium?

A

Memory issues
Perceptual or language issues
Illusions
Hallucinations

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23
Q

What are the most common biochemical disturbances causing delirium?

A

High or low sodium and high calcium

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24
Q

How can drugs cause delirium?

A

Either by acting on the brain directly, or by leading to an electrolyte disturbance, e.g. ACEi causing AKI

25
What % of in patients get delirium?
20-30%
26
What is the commonest complication of hospitalisation?
Delirium
27
What are the consequences of delirium?
Increased risk of death Longer length of stay Increased rates of institutionalisation Persistent functional decline
28
How do you diagnose delirium?
4AT | Hx
29
Who gets a 4AT?
Everyone over age 65y in hospital
30
What are the four domains of a 4AT?
Alertness AMT4 (age, DoB, place) Attention Acute change or fluctuating course
31
What does a 4AT of 4 mean?
Possible delirium -/+ cognitive impairment
32
What does a 4AT of 1-3 mean?
Possible cognitive impairment
33
What does a 4AT of 0 mean?
Delirium or severe cognitive impairment unlikely
34
How do you manage delirium?
Treat the cause (full Hx, Ex)
35
What tool is used to check for delirium triggers?
TIME bundle | Must be started within 2 hours
36
What is involved in the non-pharmacological treatment of delirium?
``` Re-orientate and re-assure patient Encourage early mobility and self care Correction of sensory impairment Normalise sleep wake cycle (natural light) Ensure continuity of care Avoid urinary catheterisation/venflons ```
37
What is involved in the pharmacological management of delirium?
Stop bad drugs Drug treatment not usually necessary, if it is must be done by senior If danger to themselves/distress that can not otherwise be settled give 12.5mg quetiapine DO NOT want to sedate (injury risk)
38
What drugs are bad in delirium and you would stop?
Anticholingerics Sedatives ACEi and NSAIDs if biochemical disturbance
39
Define dementia
Acquired decline in memory and other cognitive functions in an alert person sufficiently severe to cause functional impairment and present from more than 6 months
40
Give examples of functional impairment
Forgetting to take tablets Unable to use phone Difficult washing and dressing
41
State the 5 major dementias
``` Alzheimer's Vascular dementia Mixed Alzheimer's/vascular Dementia with Lewy bodies Reversible causes ```
42
Describe the onset of Alzheimer's
Slow, insidious Loss of recent memory first Progressive functional decline
43
What are the risk factors for Alzheimer's?
Age (biggest RF) Vascular risk factors Genetics
44
Describe the typical characteristics of vascular dementia
Step wise deterioration Executive dysfunction may predominate rather than memory impairment (e.g. problem solving and planning affected) Often associated with gait problems
45
What risk factors are associated with vascular dementia?
Vascular (e.g. type 2 DM, AF, IHD, PVD)
46
What are the characteristics of dementia with Lewy Bodies?
May have parkinsonism Often very fluctuant Hallucinations common Falls common
47
What symptoms are included in parkinsonism?
Gait issues Slow movements Rigidity
48
When is fronto-temporal dementia often diagnosed?
At earlier age
49
What are the typical characteristics of fronto-temporal dementia?
Behaviour change, e.g. aggression Language difficulties, may present like stroke/tumour/become aphasic Usually lack insight
50
What tools can be used to help diagnose dementia?
MMSE, MOCA
51
What are the issues with the MMSE and MOCA?
Culturally/generationally/intellectually specific May be falsely reassuring Remember hx is key, do not use these tools to diagnose
52
What is involved in the management of dementia?
Support for person and carers Cognitive stimulation Exercise Environmental design (e.g. signs in picture form) Avoiding changes in environment/social support Advanced care planning Drugs
53
What drugs can be used to manage dementia?
Cholinesterase inhibitors (mainly used in Alzheimer's) Galantamine licensed in mixed dementia Rivastigmine in dementia with Lewy bodies Antipsychotics (avoid if possible)
54
A demented patient on antipsychotics is at increased risk of what?
CV death
55
State some reversible causes of dementia
``` Hypothyroidism/hyperthyroidism B12 deficiency Intracranial bleeds/tumours Hypercalcaemia Normal pressure hydrocephalus Depression ```
56
What drug exacerbates lewy body dementia?
Metoclompramide (lowers dopamine levels)
57
What domains are tested in the MMSE?
``` Orientation Registration Attention and calculation Recall Language ```
58
What domains are assessed in the MOCA?
``` Visuospatial/executive Naming Memory Attention Language Abstraction Delayed recall Orientation ```

Geriatrics (13 decks)

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