Confusion in the elderly

Question 1

What are some of the causes of confusion in the elderly?

Answer 1

• Delrium
• Dementia
• Depression
• Drugs
• Metabolic

Question 2

What is delirium?

Answer 2

An acute change in congiousness and conginition

Question 3

Which drugs in particular can cause confusion in the elderly?

Answer 3

Withdrawl of:

• Morphine
• Coccaine
• Alcohol
• Zoplicone

Question 4

What is the age cut off for early/ late on set dementia?

Answer 4

Early onset: < 65 years

Late onset: > 65 years

Question 5

What is a mini mental state examination (MME)?

Answer 5

A test often used in acute care setting

Tests; orientation, regiatration, attention and calcluation, recall, language and copying

Question 6

What is the Montreal Congnitive Assessment (MOCA)

Answer 6

A test used in the neurology department

Question 7

What macroscopic changes do you see in Alzeimer’s Dementia?

Answer 7

• Global atrophy of brain lobes
  
  • mainly frontal, parietal and temporal lobes
  • occipital lobe less affected
• Sulcus widening
• Enlarged 3rd and 4th interventricular space

Question 8

What microscopic changes do you see in Alzheimer’s Disease?

Answer 8

• Senile and amyloid plaques
  
  • Derived from proteoltic breakdown of Beta amyloid precurcor protein
• Neurofibrillary tau tangles
  
  • Increase AChesterase action depleteing ACh
• Results in neuronal death

Question 9

What genetic links are associated with early onset and late onset alzheimer’s?

Answer 9

Early onset:

• Beta amyloid precursor
• Presenilin 1
• Presenilin 2

Late onset:

• Apolipoprotein E (increases permability of brain to amyloid plaques)

Question 10

What might people with Alzheimer’s disease present with?

Answer 10

• Deterioration in memory
• Deterioration in spatial navigation
• Difficulty in executive functions
  
  • language
  • visuospatial functioning
  • calculation
• Daily activities affected

Question 11

What are the 2 main classes of treatment for Alzheimer’s Disease?

Answer 11

AChE inhibitors

• Donepezil
• Galantamine
• Rivastigimine

Memantine

• ​inhibits glutamate

Question 12

What is Lewy Body dementia?

Answer 12

Presence of Lewy bodies in the brain

• Aggregation of alpha-synuclein protein
• spherical in shape
• found intra-cytoplasm
• deposits in substantia nigra, temporal lobe, frontal lobe, cingulate gyrus

Question 13

What are the 3 core clinical features of Lewy Body dementia?

Answer 13

• fluctuating congition with variations in attention and alertness
• Visual hallucinations
• Features of parkinsonism - shuffling gait, flexed posture (don’t have all the features)

Question 14

What is the main treatment of Lewy body dementia?

Answer 14

AchE inhibitors (Lewy bodies known to increase AChE activity)

• Donepezil
• Galantamine
• Rivastigmine

Memantine

Question 15

What is the pathophysiology of fronto-temporal dementia?

Answer 15

• Peak onset 55-65 years
• Atrophy of the frontal and temporal lobes

Question 16

How do patients with fronto-temporal dementia present

Answer 16

Symptoms based on lobe dysfunction

• Altered behaviour, personality, social conduct
• Appear disinhibited and apathetic
• Disorder of language - expressive dysphagia (Broca’s area affected)
• Primitive reflexes
  
  • grasp reflex
  • palmomental reflex → stroke thenar eminence and mouth opens
• Short and long term memory impairment
• Disorder of language receptive dysphagua if temporal lobe involved

Question 17

What are some of the risk factors of vascular dementia?

Answer 17

• Hypertension
• Smoking
• Diabetes
• Vascular disease
• Occurs due to cerebrovascular disease

Question 18

How does vascular dementia present?

Answer 18

Stepwide deterioration of cognitive function with focal neurological symtpoms due to multiple CVA- damaged brain doesn’t return to previous level of function

Question 19

How can you treat vascular dementia?

Answer 19

• Risk factor management - lifestyle modification
• Only treat if they have another type of dementia underlying
  
  • AchE inhibitors
  • Memantine

Question 20

What is the AIDs dementia complex (ADC)?

Answer 20

• HIV infected macrophages can enter the brain and cause indirect neurone damage
• Insidious onset but once established causes rapid progression

Question 21

How can AIDS- dementia complex present?

Answer 21

• Cognitive impairment
• Psychomotor retardation
• Tremor
• Ataxia
• Dysarthria
• Incontinence

Very non specific symtpoms due to global impairment of the brain

Question 22

How can you treat AIDs-Dementia Complex?

Answer 22

Anti-Virals

Question 23

What common investigations should you do for all suspected dementia cases?

Answer 23

Need to be done within 6 months of recording a new diagnosis:

• FBC
• U&E
• ESR / CRP
• TFT (thryoid function)
• LFTs
• Random blood sugar
• Vitamin B12 and folate

Question 24

What biopsychosocial help should patients with dementia be helped with?

Answer 24

• Mobility problems
• Activities of daily living
• Ability to learn new skills
• Financial problems

Question 25

What are the 2 types of delirium?

Answer 25

Hypoactive and Hyperactive

Or a mix of the 2

Question 26

What are some of the causes of delirium?

Answer 26

DELIRIUM menumonic

• Drugs toxicity:
  
  • withdrawl of alcohol, benzodiazepines, cocaine, coffee
  • anticholinergics, opiates, antihistamines etc
• Endocrine
  
  • hyper/ hypothyroidism
  • Addison’s
  • Cushing’s disease
• Liver failure
• Intracranial: stroke, haemorrhage, cerebral abscess, epilepsy
• Renal Failure
• Infections: Pneumonia, UTI, Sepsis, Meningitis
• Urinary retention/ faecal retention
• Metabolic
  
  • electrolyte imbalance
  • hypoxia

Question 27

What investigations should you do to if a patient presents with delerium?

Answer 27

• Blood tests (FBC, U&E, CRP, TFT, LFT, random blood sugar, blood culture)
• Bedside tests
  
  • urine dip
  • O₂ sats
• Radiological tests
  
  • CXR
  • CT head
• Review current drug history

Question 28

How do you treat delerium?

Answer 28

Treat the underlying cause

• calm environment
• rehydration
• haloperidol (only if essential)