Confusion In The Elderly Patient Flashcards
5 main causes of confusion in elderly patients and definitions of them
Delirium - acute change in consciousness and cognition
Dementia - cognitive decline due to disease of the brain
Depression - change in mood and feeling of self- worth
Metabolic/ endocrine - hypothyroidism, hypercalcaemia, VB12 deficiency, normal pressure hydrocephalus
Drugs - morphine, coccaine, alcohol, zopiclone
What is dementia? Types
Progressive usually
Impairment memory/ intellect/ personality
Failure individual to cope with everyday affairs
Early onset (before 65yrs) and late onset
- Alzheimer’s dementia
- dementia with Lewy bodies
- vascular dementia
- fronto- temporal dementia
- AIDS- dementia complex
Who do you refer to as a GP if you suspect dementia, what would be the next stage?
Memory clinic and then old age psychiatrist if symptoms not controlled
What tests are used for cognition in acute care and in the neurology?
Acute care: mini mental state examination
Neurology: Montreal cognitive assessment (MOCA)
Macroscopic changes in Alzheimer’s dementia
Causes global atrophy of brain lobes - mostly frontal, partial and temporal
- sulcus widening
- enlarged 3/4th interventricular spaces
Microscopic changes in Alzheimer’s dementia
- Senile amyloid plaques (from proteolytic breakdown from beta amyloid precursor protein)
- neurofibrillary tau tangles
- > neuronal death
Genetic markers for Alzheimer’s
Early onset:
Beta amyloid precursor protein, presenilin 1/2 (from beta amyloid precursor protein breakdown)
Late onset: aPolipoprotein E gene (increases permeability of brain to amyloid plaque)
Complaints with Alzheimer’s
Detoriation memory/ special navigation
Difficulty: language, visuospatial functioning, calculation
Treatment of Alzheimer’s and dementia with Lewy bodies, vascular dementia pharmaceutical
- AChE inhibitors - amyloid plaques decrease Ach -> neurones did so inhibit ACh esterase e.g. donepezil
- memantine - inhibits glutamate action in brain
Pathophysiology of dementia with Lewy bodies
Lewy bodies Aggregation of alpha- synuclein protein Spherical Intra- cytoplasm Deposits in substantia nigra, temporal/ frontal lobe, cingulate gyrus
3 main clinical features of dementia with LB
- fluctuating cognition with variations in attention
- visual hallucinations
Later: Parkinsonism features shuffling gait, flexed posture (different to Parkinson’s where these come first)
Pathophysiology of fronto-temporal dementia
2nd commonest cause early- onset
Peak 55-65yrs
Atrophy of frontal and temporal lobes
Presenting complaints of fronto-temporal dementia
- altered behaviour/ personality
- disinhibited and apathetic
- disorder of language - expressive dysphasia/ non fluent aphasia
- primitive reflexes (grasp reflex/ palmomental reflex)
- memory impairment
- receptive dysphasia/ fluent aphasia
Risk factors for vascular dementia and cause
Hypertension
Smoking diabetes
Vascular disease
Due to cerebrovascular disease (ischaemia or haemorrhagic)
Presenting complaint of vascular dementia
Step wise decline in cognitive performance in vascular dementia
Peaks and gradual overall decline
Pathophysiology of AIDS- dementia complex
Increased prevalence
HIV infected macrophages enter brain -> indirect neuronal damage
Insidious onset but rapid progression
Presenting complaints of AIdS- dementia and treatment
Cognitive impairment Psychomotor retardation Tremor Ataxia Dysarthria Incontinence
✅antivirals
Common investigations of dementia cases
Within 6 months of recording new diagnosis
FBC U&Es ESR or CRP TFTs LFTs Random blood sugar VB12 and folate
Routine syphilis testing not necessary
Management for dementia
Bio- psycho social model Mobility problems, daily activities, Learn new skills ability, Financial problems
What is delirium?
Confusion assessment method:
- acute onset of altered mental status and fluctuating course
- inattention
- disordered thinking
- altered level of consciousness (main difference with dementia)
What are the two types of delirium?
Hyperactive and hypoactive
Most the time alternate between the two
Causes of delirium
Drugs toxicity (withdrawal alcohol, benzodiazepines, coaching, caffeine. Anti-cholinergics, opiates, anti-histamines, dopamine agonist, levodopa, anti depressants)
Endocrine - hyper/ hypothyroidism, addisonsons, Cushing
Liver failure
Intracranial (stroke/ haemorrhage/ cerebra, abscess/ epilepsy)
Infections - most common pneumonia, UTI, sepsis, meningitis
Urinary retention/ faecal retention
Metabolic - electrolyte imbalance (Na, Ca, Mg, Po, glucose)
Hypoxia
Believed cause of delirium
Complex
Cholinergic- dopaminergic imbalance
Investigations of delirium
FBC U&Es ESR/ CRP TFTs LFTs Random blood sugars Blood culture - sepsis
Urine dip
Oxygen sats
CXR
CT head
Review drug history
