Confusion Flashcards
What are the difficulties in trying to define confusion
Can be a brain problem Deafness Asking someone to do something that is too difficult Culture differences Etc
What is it better to think about rather than confusion?
Cognition
What are the six neurocognitive domains and subdomains in DSM5?
Complex attention Perceptual-motor function Language function Executive function Learning/memory Social cognition
What is involved in complex attention?
Sustained attention
Divided attention
Selective attention
Processing speed
What is involved in perceptual-motor function?
Visual perception
Visuoconstructional reasoning
Perceptual-motor co-ordination
What is involved in language function?
Object naming Word finding Fluency Grammar and syntax Receptive language
What is involved in executive function?
Planning Decision making Working memory Responding to feedback Inhibition Flexibility
What is involved in learning and memory?
Free recall Cued recall Recognition memory Semantic and autobiographical long term memory Implicit learning
What is involved in social cognition?
Recognition of emotions
Theory of mind
Insight
Why is assessing cognition of value?
?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
What is the reversible cause of confusion?
Delirium
What is key in diagnosing cause of the cognitive impaired?
History Collateral history (GP, family etc.)
What do you want to know from the history of a confused person?
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)
What are the key features of delirium?
Disturbance consciousness
Changes in cognition
Acute onset & fluctuant
Generally worse at night
What are the two kinds of delirium?
Hyperactive delirium
Hypoactive delirium
Often a mix
What is hyperactive delirium?
Restless, exploring environment, agitated
What is hypoactive delirium?
Abnormally sleepy
(Lethargic, sedated, stupor)
(sometimes hard to stop)
What are some other common features of delirium?
Disturbed sleep wake cycle
Disturbed psychomotor behaviour (more likely to fall)
Emotional disturbance
Who does delirium tend to affect?
Those at extremes of age
Those who are frail or have cognitive frailty (e.g. dementia, parkinsons, MS etc.)
Why is the proposed mechanism for delirium?
Maladaptive pro-inflammatory response
What are some common precipitants of delirium?
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
What kind of changes in cognition can occur with delirium?
Memory issues
Perceptual or language issues
Illusions
Hallucinations
What are the most common biochemical disturbances causing delirium?
High or low sodium and high calcium
How can drugs cause delirium?
Either by acting on the brain directly, or by leading to an electrolyte disturbance, e.g. ACEi causing AKI
What % of in patients get delirium?
20-30%
What is the commonest complication of hospitalisation?
Delirium
What are the consequences of delirium?
Increased risk of death
Longer length of stay
Increased rates of institutionalisation
Persistent functional decline
How do you diagnose delirium?
4AT
Hx
Who gets a 4AT?
Everyone over age 65y in hospital
What are the four domains of a 4AT?
Alertness
AMT4 (age, DoB, place)
Attention
Acute change or fluctuating course
What does a 4AT of 4 mean?
Possible delirium -/+ cognitive impairment
What does a 4AT of 1-3 mean?
Possible cognitive impairment
What does a 4AT of 0 mean?
Delirium or severe cognitive impairment unlikely
How do you manage delirium?
Treat the cause (full Hx, Ex)
What tool is used to check for delirium triggers?
TIME bundle
Must be started within 2 hours
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
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)
What drugs are bad in delirium and you would stop?
Anticholingerics
Sedatives
ACEi and NSAIDs if biochemical disturbance
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
Give examples of functional impairment
Forgetting to take tablets
Unable to use phone
Difficult washing and dressing
State the 5 major dementias
Alzheimer's Vascular dementia Mixed Alzheimer's/vascular Dementia with Lewy bodies Reversible causes
Describe the onset of Alzheimer’s
Slow, insidious
Loss of recent memory first
Progressive functional decline
What are the risk factors for Alzheimer’s?
Age (biggest RF)
Vascular risk factors
Genetics
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
What risk factors are associated with vascular dementia?
Vascular (e.g. type 2 DM, AF, IHD, PVD)
What are the characteristics of dementia with Lewy Bodies?
May have parkinsonism
Often very fluctuant
Hallucinations common
Falls common
What symptoms are included in parkinsonism?
Gait issues
Slow movements
Rigidity
When is fronto-temporal dementia often diagnosed?
At earlier age
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
What tools can be used to help diagnose dementia?
MMSE, MOCA
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
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
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)
A demented patient on antipsychotics is at increased risk of what?
CV death
State some reversible causes of dementia
Hypothyroidism/hyperthyroidism B12 deficiency Intracranial bleeds/tumours Hypercalcaemia Normal pressure hydrocephalus Depression
What drug exacerbates lewy body dementia?
Metoclompramide (lowers dopamine levels)
What domains are tested in the MMSE?
Orientation Registration Attention and calculation Recall Language
What domains are assessed in the MOCA?
Visuospatial/executive Naming Memory Attention Language Abstraction Delayed recall Orientation
