Confusion in the Elderly Flashcards
1
Q
Mental health and aging
A
- Cognitive loss
- Psycological diseases of old age
- Psychosocial issues of the elderly
- Medical legal issues (MDM capacity, dpoa – designated power of attourney)
2
Q
Confusion: the common denominator
A
- Wrongly believed to be due to aging
- The medical differential diagnosis
- The in-the-trenches differential diagnosis: the three D’s
- You should, for any sx, be able to produce a differential for any give sx
3
Q
The three Ds
A
- Dementia
- Delirium
- Depression
- If you have altered level of consciousness, these should be your first differentials
4
Q
Confusion in the elderly
A
- Confusion is variable – the question is how does the confusion present
- Constant versus intermittent – this tells you a lot!
- If you get a UTI, the confusion is intermittent (you won’t be confused for the rest of your life)
- Acute versus chronic – Parkinson’s doesn’t hit you over night –> if all of a sudden you have all the sxs, that’s NOT Parkinson’s, its probably a side effect from an antipsychotic
- Differs from symptoms of mental illness in younger people – not everyone has the same adverse drug effects
- BASELINE –> very important in discussion of cognition
- If their baseline is nonverbal and you assess them and they can’t talk, this is NORMAL FOR THEM
- No new schizophrenia in old age (but lots of antipsychotics)
- Antipsychotics are used to treat agitation and aggression in the ER and they are also the preferred tx for schizophrenia
- YOU CAN’T BE A CRACK HEAD AND BE CONSIDERED SCHIZOPHRENIC –> you can’t be on any influence when diagnosed
- Constant versus intermittent – this tells you a lot!
5
Q
Dementia
A
- Hallmark: loss of recent memory
- Insidious onset
- Impaired judgement
- Behavioral issues
- Sleep disturbance
- Aggression
- Early versus late issues
- Early dementia is not the same as late dementia
- Demented people lose their ability to perform ADLs
6
Q
Diseases that cause dimentia
A
- Alzheimer’s disease 70%
- Multi-infarct (stroke)
- Lewy body (amyloid plaques)
- HIV – late stage HIV people
7
Q
Diseases associated with dimentia
A
- Parkinson’s disease
- B12 deficiency
- Thyroid disease
- Liver disease
- Encephalopathy – certain disease processes cause encephalopathy (i.e. Hep C, kidney issues)
- These are not dementia in and of themselves but they create dementia à you can use these to prevent dementia
8
Q
Alzheimers dz probable criteria
A
- Dementia
- Clinical exam eg r/o others
- Mental status evaluation
- Deficits in >2 cognitive areas
- Progressive decline
- Normal level of consciousness (encephalopathy is NOT a normal level of consciousness)
- Onset between 40-90 yrs
- No other cause
- Supportive factors
- +family hx
- Cerebral atrophy
- Normal EEG
- Normal lumbar puncture
- Clinical criteria + histopathology
9
Q
Alzheimers dz definite criteria
A
- Risks:
- Nonmod: age, fam hx, APOE-4 gene, down syndrome
- Mod: head trauma, HTN, DM, smoking, depression
- Age:
- Prevalence of AD doubles every 5yrs > 60
- 85yo has 50% risk of AD
- 2x parents with AD = 54% risk by 80yo
- 1st degree relative with AD: risk is double that of general population
10
Q
Stages of Alzheimers
A
- Early
- Gradual memory loss
- Preserved level of consciousness à they’re aware of where they are, they know whats going on
- Impaired ADLs
- Subtle language errors
- Impaired spatial perception à they are at an increased fall risk
- Late
- Aphasia: no speaking
- Apraxia: no purposeful actions – think walking à people can walk, but they don’t know where they’re walking to
- Agnosia: no recognizing/interpreting – they have a hard time understanding language, they cant interpret things in the way that you mean them
- Inattention
- Left-right confusion – you say left and they reach to their right
11
Q
Dementia ddx
A
- Agnosia, aphasia an apraxia shared with other dementias
- AD specific: word finding issues, apathy/indifference, delusion, disorientation
- Delusion = woman who had uterine cancer and refuses blood transfusion because she doesn’t want other people’s blood and she is going to leave and drive across the country
12
Q
Lewy body dementia
A
-
Mild Parkinsonism sxs (shaking, tremor gait)
- Parkinsonism sxs: pill rolling tremor on one side or both sides, shaking, masked facies, shaking
- Unexplained falls
- Visual hallucinations – talking to someone under the bed
- Fluctuating cognition – sometimes theyre with you and sometimes they are not
- Extreme sensitivity to antipsychotic medications
- Confirmation dx: +amyloid plaques on PET scan à DIAGNOSTIC TEST!!
- 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
13
Q
Frontotemporal dementia
A
- Onset before 60
- Language disarray
- Profound personality changes
- Behavioral issues – have a very odd affect
- Impulsive – have no impulse control
- Hypersexual – sexually motivated
14
Q
Type of Frontotemporal dementias
A
- Progressive supranuclear palsy: PSP a degenerative disease of specific regions of brain
- Primary progressive aphasia: language slowly impaired, not other mental functions
- Semantic dementia: loss of word meaning
- ALS with dementia: Amytrophic lateral sclerosis (neurogenerative dz)
15
Q
Vascular dementia - multiinfarct dementia
A
- Stepwise deterioration 2/2 (secondary to) ischemic events
- Normal level of consciousness
- Functional loss may correlate with cerebrovascular events (CT/MRI)
- Types: cortical, subcortical, white matter lesions, mixed or specific – all depend on where the stroke is!
- They have a stepwise approach – every time they have a stroke, their symptomology changes a bit
- YOU DON’T WANT TO MISS VASCULAR EVENTS!!! It’s a red flag! You need to ALWAYS consider a vascular even
- You can get a CAT scan or MRI to confirm
- You don’t get a CAT scan on everyone you think has dementia
- ACUTE ONSET à TELLS YOU TO GET A SCAN!!!
