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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
Supportive Factors for AD
+ Family History Cerebral Atrophy Normal EEG Normal Lumbar Puncture
26
what sxs are shared by all the dementia
Agnosia, aphasia an apraxia shared with other dementias
27
what sxs are specific to dementia
word finding issues, apathy/ indifference, delusion, disorientation.
28
delusions
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.
29
Lewy Body Dementia
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
Parkinson's sxs (4)
shuffling gait masked faces (can't emot) pill rolling tremor inability to maintain upright posture
31
if worried about Lewy Body
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
A diagnosis of Lewy body dementia requires
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
Frontotemporal Dementia | onset
before 60 seen in frontal and lateral regions
34
frontotemporal dementia
Language Disarray Profound Personality Changes Behavioral Issues IMPULSIVE Hypersexual
35
Stepwise Deterioration 2/2 ischemic events
Vascular Dementia
36
Normal Level of Consciousness | Functional Loss may Correlate with Cerebrovascular Events (CT/MRI)
Vascular Dementia
37
types of vascular dementia
cortical, subcortical, white matter lesions, mixed or specific
38
when would you be more likely to order a CAT scan
acute onset
39
when would you see cortical/subcortical infarct and white matter lesions
vascular dementia
40
what do you have to rule out
infarcts strokes utilize imaging but only when needed
41
screening for dementia
MMSE | MOCA
42
strengths of MMSE
standardized, widely used reproducible validity quickly administered useful scoring
43
limitations of MMSE
``` does not test executive function not correlative with capacity screening tool education dependent not culturally valid ```
44
tx of vascular risk factors
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
neuroprotection
folate and vit B12 mediterranean diet moderate alchol consumption
46
building up neuronal reserves
cognitive activity physical activity social and leisure activity
47
intervention for mild cog impairment
cognitive enhancers (donepezil and memantine only for 6 mo)
48
what to rule out on confusion ddx
``` Medications surgery infection dehydration laboratory abnormalities associated with other disease process, e.g., cancer, collagen vascular disease, MI, Dem, Dep ```
49
what % or people with hip surgery experience delirium
40-52%
50
postoperative older adultes undergoing elective major non-cardiac surgery experience delirium at what %
10-39%
51
anticholinergic SE
``` hot as a hare dry as a bone blind as a bat red as a beet mad as a hatter ```
52
how do you dx dehydration
<20/1BUN to creatinine
53
what % of elders experience depression
40%
54
SIG E CAPS
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
RF for depression
chronic mental illness loss of a loved one relocation disability
56
considerations with depression in older pts
somatic complaints masked depression higher incidence of minor depression depression and dementia are frequently intertwined in older people
57
what co-morbidities are correlated with depression
stroke and heart disease
58
why should elderly people be treated for depression
more likely to die improved morbidity and mortality with antidepressants
59
ddx for depression
hypo/hyper thyroid vitamin deficiency anemia UTI
60
lab tests for ddx of depression
TSH B12 CBC w/ diff UA
61
diagnoses of depression
PHQ-2 NEUROPSYCH CONSULT
62
PHQ2
83% sensitive
63
what lab tests do you want to run following depression tx
***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
Buproprion (wellbutrin ) benefits
Buproprion: no sex SE, no weight gain no GIB.
65
TCA considerations in elderly
TCAs: SE: anticholinergic, increase HR, orthostasis, monitor EKG!
66
tx for depression
``` CBT: cognitive behavioral therapy PST: problem solving therapy TIP: treatment initiation and participation ECT: electroconvulsant therapy TCA buproprian SNRI SSRI ```
67
% binge drinkers in the last month
5.6% Binge Drinking in the Last Month
68
how many elders have alcohol abuse
2 Million Elders have Alcohol Issues
69
MCV in alcohols
MCV is the size of the RBC
70
macrocytic anemia
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
microcytic anemia
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
Capacity Guidelines
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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