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Geriatrics > Confusion in the Elderly > Flashcards

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)
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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
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3
Q

The three Ds

A
  • Dementia
  • Delirium
  • Depression
  • If you have altered level of consciousness, these should be your first differentials
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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
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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
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6
Q

Diseases that cause dimentia

A
  • Alzheimer’s disease 70%
  • Multi-infarct (stroke)
  • Lewy body (amyloid plaques)
  • HIV – late stage HIV people
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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
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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
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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
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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
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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
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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
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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
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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)
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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!!!
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16
Q

Confusion in the elderly: dementia

A
  • Diagnosis
    • “rule-out” treatable causes (e.g. other D’s)
    • The role of imaging
    • Mental status
      • Screening
        • MMSE
        • MOCA
      • Full assessment
  • Treatment and management
    • Education of patient and family
    • Rx
    • Develop strategy for caregiver respite
    • Long-term care planning
17
Q

Mini mental state exam

A
  • Strengths
    • Standardized, widely used
    • Reproducible validity
    • Quickly administered
    • Useful scoring
  • Limitations
    • Does not test executive function
    • No correlative with capacity
    • Screening tool
    • Education dependent
    • Not culturally valid
18
Q

Montreal cognitive assessment

A
  • Visuospatial/Executive
  • Naming
  • Memory
  • Attention
  • Language
  • Abstraction
  • Delayed recall
  • Orientation
19
Q

Dementia management

A
  • Facilitate environmental success
  • Stimulate cognitive function with challenges
  • Promote feelings of pleasure
  • Don’t force it
20
Q

Confusion in the elderly: delirium

A
  • Acute onset
  • Waxing and waning course
  • Common in the hospital
  • Memory, orientation, perception, sleep, speech, consciousness and psychomotor hypo and hyper active or mixed changes. Cx: stress causes metabolic changes
  • Vast differential diagnosis
    • Medications
    • Surgery
    • Infection
    • Dehydration
    • Laboratory abnormalities
    • Associated with other disease process, e.g., cancer, collagen vascular disease, MI, dem, dep
  • Marked increase in mortality rate
  • Treatment
    • Treat the underlying problem
    • Orientation strategies
21
Q

Confusion in the elderly: depression

A
  • 40% of elders experience depression
  • Elders do not recognize (or acknowledge) their depression
  • Elderly males are the highest suicide risk
  • Depression more likely to lead to Parkinson’s dz, alzheimer’s disease, stroke
  • s/p stroke: increased likelihood for major/minor depression
  • Common symptoms
    • Loss of energy and enthusiasm
    • Sleep change: early morning awakening
    • Weight loss
    • Anxiety and perplexing
  • Diagnosis: PHQ-2, PH!-9
    • PHQ2: lack of interest, depressed mood? Yes to both is 83% sensitive!
  • Treatment
    • Medication
    • Counseling
    • Education
22
Q

Depression sx

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
23
Q

Depression treatment

A
  • 1) SSRI:primary treatment, risk of Serotonin syndrome
    • Can cause impotence and weight gain
  • 2)SNRI: better for neuropathic pain, eg. Remeron
  • ***1 & 2: check Na in 2 wks if on other rx that effect ADH (diuretics NSAIDS, Monitor for GIB/nsaid/asa
    • Can create problems with sodium metabolism
  • 3) Buproprion: no sex SE, no weight gain no GIB.
  • 4) TCAs: SE: anticholinergic, increase HR, orthostasis, monitor EKG!
24
Q

Other depression treatments

A
  • CBT: cognitive behavioral therapy
  • PST: problem solving therapy
  • TIP: treatment initiation and participation
  • ECT: electroconvulsant therapy
25
Q

Mental health issues of the elderly

A
  • Loneliness
  • Boredom
  • Vulnerability
  • Impaired Self-Assessment Skills
  • Loss
    • Home
    • Loved Ones
    • Respect of the Community
  • Substance abuse
  • Alcohol use/abuse
26
Q

Alcohol and elders

A
  • 5.6% Binge Drinking in the Last Month
  • 2 Million Elders have Alcohol Issues
  • High Risk Drinkers
    • 15% Men
    • 12% Women
  • Stressful Life Events may be Triggers
27
Q

Screening for alcohol use

A
  • Ask!
  • Laboratory Clues
    • Gamma-glutamyl Transpeptidase (GGT) enzyme in liver that indicates liver dz
    • Mean Corpuscular Volume (MCV) – size of the red blood cell
      • Microcytic anemia is secondary to GI bleed
      • Macrocytic anemia = depletion of folate and B12 à ALCOHOLICS!!
    • Carbohydrate-deficient Transferring (CDT) 4-5 etoh proportion of transfer with fewer chains increased
  • Screening: CAGE
  • C: felt you should cut down
  • A: been annoyed by others’ concerns
  • G: feel guilty about your drinking
  • E: ever taken a drink first thing in the morning as an eye-opener
28
Q

Alcohol and aging

A
  • Low-risk Drinking
  • At-risk Drinking
  • Alcohol Abuse
  • Alcohol Dependence
29
Q

Mental health of the elderly

A
  • End of Life Issues
    • Recognition of Time Limitations
    • Hearing Bad News
    • Accepting Bad News
    • Preparing for Death
30
Q

Capacity vs. Competence

A
  • Capacity versus Competence
    • Medical vs legal eg MDM capacity with DPOA
  • Issue by Issue Determination
  • Capacity Guidelines
    • cognitive status
    • ability to appreciate the problem and its consequences
    • ability to discriminate risks versus benefits of treatments
31
Q

Assessment of capacity

A
  • Age
  • Physical Health
  • Activities of Daily Living
  • Mental and Emotional Health
  • Substance Abuse
  • Acceptance of Services
  • Financial Resources
  • Environment
  • Orientation
  • Does the Client Understand…
    • the Situation?
    • The Potential Consequences of the Situation?
    • Their Own Limitations in the Situation and the Alternatives Available?

Geriatrics (7 decks)

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