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Geriatrics > confusion in the elderly > Flashcards

confusion in the elderly Flashcards

1
Q

dpoa

A

designated power of attorney

plays a role in mdm

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2
Q

medical ddx for confusion

A

literally everything but you want to focus on the three D’s as your categories

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3
Q

the three D’s

A

dementia
delirium
depression

not mutually exclusive

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4
Q

to avoid overshooting you have to start thinking in

A

categories

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5
Q

what are the factors you want to consider when thinking about the variable of confusion

A

constant versus intermittent
(Parkinson’s vs UTI)

acute vs chronic
(Parkinson’s isn’t overnight that is a medication SE)

differs from symptoms of mental illness in younger people

no new schizophrenia in old age ( but lots of antipsychotics )

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6
Q

what is the epidemic we see with poor people and schizophrenia dx

A

antipsychotics are the preferred treatment for agression in the ED but are also the preferred tx for schizophrenia

this is why we see poor people and people on meth labeled as “schizophrenic”

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7
Q

hallmark of dementia

A

loss of recent memory

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8
Q

what are the signs of dementia

A

progressive
insidious (slow)
impaired judgement (i.e. catheter dude with EF of 13%)
behavioral issues

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9
Q

TBI

A

traumatic brain injury seen with overnight dementia

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10
Q

early vs late issues

A

need to know the difference between early and late dementia

what can you do about it
what is the pathological process
and what stage are they at

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11
Q

most common dementia

A

alzheimers dementia (70%)

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12
Q

multi-infarct dementia results from

A

strokes

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13
Q

multiple causes of dementia

A
  • Alzheimer’s Disease 70%
    • Multi-infarct
    • Lewy Body
      • Parkinson’s dementia
    • HIV in late stage
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14
Q

dz associated with dementia that confound dementia (different trajectory)

A

Parkinson’s Disease

B12 deficiency

Thyroid Disease

Liver Disease

encephalopathy (liver cirrhosis and hep c as well as untreated ESRF)

can use these factors to prevent the progression dementia

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15
Q

clinical way of dx dementia

and

definitively dx

A

need to rule out delirium and depression

looking for pregressive decline and deficits in at least 2 area

normal level of consciousness

onset is VITAL 40-90

can only definitively dx post mortem

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16
Q

onset of dementia

A

40-90

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17
Q

what does the progression of cognitive decline look like in AD pts

A

first 1/3 normal cog impairement
mild 2nd 1/3
last 1/3 functional decline

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18
Q

non modifiable rf for AD

A

age, fam hx, APOE-4 gene, downs syndrome

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19
Q

modifiable RF for AD

A 
head trauma
HTN
DM
smoke
Depression
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20
Q

prevalence of AD doubles at what age

A

prevalence of AD doubles q 5 yrs >60

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21
Q

85 risk of dementia

A

85 yo has 50% risk of AD

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22
Q

2x parents with AD risk

A

2x parents with AD=54% risk by 80yo

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23
Q

1st degree relative with AD: risk

A

1st degree relative with AD: risk is double that of general population

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24
Q

early stages of alzheimer’s

A 
Gradual Memory Loss
Preserved Level of Consciousness
Impaired ADLs
Subtle Language Errors
Impaired Spatial Perception
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25
Q

Supportive Factors for AD

A

+ Family History
Cerebral Atrophy
Normal EEG
Normal Lumbar Puncture

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26
Q

what sxs are shared by all the dementia

A

Agnosia, aphasia an apraxia shared with other dementias

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27
Q

what sxs are specific to dementia

A

word finding issues, apathy/ indifference, delusion, disorientation.

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28
Q

delusions

A

an idiosyncratic belief or impression that is firmly maintained despite being contradicted by what is generally accepted as reality or rational argument, typically a symptom of mental disorder.

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29
Q

Lewy Body Dementia

A

not nearly as common as AD

Mild Parkinsonism Symptoms (all 4 seen in Lewy body)

Unexplained Falls

Visual Hallucinations

Fluctuating Cognition

Extreme Sensitivity to Antipsychotic Medications (get Parkinsonian effects hard to tell which came first chicken or the egg)

Confirmation dx : +amyloid plaques on PET scan

30
Q

Parkinson’s sxs (4)

A

shuffling gait

masked faces (can’t emot)

pill rolling tremor

inability to maintain upright posture

31
Q

if worried about Lewy Body

A

take them off antipsychotics because this could make it work

if they are still talking tot the wall

send them to a neurologist who will do a PET scan for amyloid plaques

32
Q

A diagnosis of Lewy body dementia requires

A

A diagnosis of Lewy body dementia requires….

a progressive decline in your ability to think, as well as two of the following:

Fluctuating alertness and thinking (cognitive) function.

Repeated visual hallucinations.

Parkinsonian symptoms.

33
Q

Frontotemporal Dementia

onset

A

before 60

seen in frontal and lateral regions

34
Q

frontotemporal dementia

A

Language Disarray

Profound Personality Changes

Behavioral Issues

IMPULSIVE

Hypersexual

35
Q

Stepwise Deterioration 2/2 ischemic events

A

Vascular Dementia

36
Q

Normal Level of Consciousness

Functional Loss may Correlate with Cerebrovascular Events (CT/MRI)

A

Vascular Dementia

37
Q

types of vascular dementia

A

cortical, subcortical, white matter lesions, mixed or specific

38
Q

when would you be more likely to order a CAT scan

A

acute onset

39
Q

when would you see cortical/subcortical infarct and white matter lesions

A

vascular dementia

40
Q

what do you have to rule out

A

infarcts
strokes

utilize imaging but only when needed

41
Q

screening for dementia

A

MMSE

MOCA

42
Q

strengths of MMSE

A

standardized, widely used
reproducible validity
quickly administered
useful scoring

43
Q

limitations of MMSE

A 
does not test executive function
not correlative with capacity
screening tool
education dependent
not culturally valid
44
Q

tx of vascular risk factors

A

treat HTN to <140/90

Treat hypercholesterolemia to LDL<100

treat DM to HbA<7

prescribe aspirin in persons with established cardiovascular dz

manage hf

smoking cessation

45
Q

neuroprotection

A

folate and vit B12
mediterranean diet
moderate alchol consumption

46
Q

building up neuronal reserves

A

cognitive activity physical activity

social and leisure activity

47
Q

intervention for mild cog impairment

A

cognitive enhancers (donepezil and memantine only for 6 mo)

48
Q

what to rule out on confusion ddx

A 
Medications
surgery
infection
dehydration
laboratory abnormalities
associated with other disease process, e.g., cancer, collagen vascular disease, MI, Dem, Dep
49
Q

what % or people with hip surgery experience delirium

A

40-52%

50
Q

postoperative older adultes undergoing elective major non-cardiac surgery experience delirium at what %

A

10-39%

51
Q

anticholinergic SE

A 
hot as a hare
dry as a bone
blind as a bat
red as a beet
mad as a hatter
52
Q

how do you dx dehydration

A

<20/1BUN to creatinine

53
Q

what % of elders experience depression

A

40%

54
Q

SIG E CAPS

A

Sleep – increased or decreased (if decreased, often early morning awakening)
Interest – decreased
Guilt/worthlessness
Energy – decreased or fatigued
Concentration/difficulty making decisions
Appetite and/or weight increase or decrease
Psychomotor activity – increased or decreased
Suicidal ideation

55
Q

RF for depression

A

chronic mental illness

loss of a loved one

relocation

disability

56
Q

considerations with depression in older pts

A

somatic complaints

masked depression

higher incidence of minor depression

depression and dementia are frequently intertwined in older people

57
Q

what co-morbidities are correlated with depression

A

stroke and heart disease

58
Q

why should elderly people be treated for depression

A

more likely to die

improved morbidity and mortality with antidepressants

59
Q

ddx for depression

A

hypo/hyper thyroid
vitamin deficiency
anemia
UTI

60
Q

lab tests for ddx of depression

A

TSH
B12
CBC w/ diff
UA

61
Q

diagnoses of depression

A

PHQ-2

NEUROPSYCH CONSULT

62
Q

PHQ2

A

83% sensitive

63
Q

what lab tests do you want to run following depression tx

A

***1 & 2: check Na in 2 wks if on other rx that effect ADH (diuretics NSAIDS, Monitor for GIB/nsaid/asa

SSRI, SNRI, and antipsychotics can all create sodium problems

64
Q

Buproprion (wellbutrin ) benefits

A

Buproprion: no sex SE, no weight gain no GIB.

65
Q

TCA considerations in elderly

A

TCAs: SE: anticholinergic, increase HR, orthostasis, monitor EKG!

66
Q

tx for depression

A 
CBT: cognitive behavioral therapy
PST: problem solving therapy
TIP: treatment initiation and participation
ECT: electroconvulsant therapy
TCA 
buproprian
SNRI
SSRI
67
Q

% binge drinkers in the last month

A

5.6% Binge Drinking in the Last Month

68
Q

how many elders have alcohol abuse

A

2 Million Elders have Alcohol Issues

69
Q

MCV in alcohols

A

MCV is the size of the RBC

70
Q

macrocytic anemia

A

macro

depletion of folate and B12

macrocytic class of anemia is an anemia (defined as blood with an insufficient concentration of hemoglobin) in which the red blood cells (erythrocytes) are larger than their normal volume. The normal erythrocyte volume in humans is about 80 to 100 femtoliters (fL= 10−15 L).

71
Q

microcytic anemia

A

is defined as the presence of small, often hypochromic, red blood cells in a peripheral blood smear and is usually characterized by a low MCV (less than 83 micron 3). Iron deficiency is the most common cause of microcytic anemia.

72
Q

Capacity Guidelines

A

cognitive status

ability to appreciate the problem and its consequences

ability to discriminate risks versus benefits of treatments

get a neuro psych assessment
defer to family
check in with medical staff

Geriatrics (12 decks)

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