Confusion In The Elderly Patient

Question 1

5 main causes of confusion in elderly patients and definitions of them

Answer 1

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

Question 2

What is dementia? Types

Answer 2

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

Question 3

Who do you refer to as a GP if you suspect dementia, what would be the next stage?

Answer 3

Memory clinic and then old age psychiatrist if symptoms not controlled

Question 4

What tests are used for cognition in acute care and in the neurology?

Answer 4

Acute care: mini mental state examination

Neurology: Montreal cognitive assessment (MOCA)

Question 5

Macroscopic changes in Alzheimer’s dementia

Answer 5

Causes global atrophy of brain lobes - mostly frontal, partial and temporal

• sulcus widening
• enlarged 3/4th interventricular spaces

Question 6

Microscopic changes in Alzheimer’s dementia

Answer 6

• Senile amyloid plaques (from proteolytic breakdown from beta amyloid precursor protein)
• neurofibrillary tau tangles
• > neuronal death

Question 7

Genetic markers for Alzheimer’s

Answer 7

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)

Question 8

Complaints with Alzheimer’s

Answer 8

Detoriation memory/ special navigation

Difficulty: language, visuospatial functioning, calculation

Question 9

Treatment of Alzheimer’s and dementia with Lewy bodies, vascular dementia pharmaceutical

Answer 9

• AChE inhibitors - amyloid plaques decrease Ach -> neurones did so inhibit ACh esterase e.g. donepezil
• memantine - inhibits glutamate action in brain

Question 10

Pathophysiology of dementia with Lewy bodies

Answer 10

Lewy bodies
Aggregation of alpha- synuclein protein 
Spherical
Intra- cytoplasm
Deposits in substantia nigra, temporal/ frontal lobe, cingulate gyrus

Question 11

3 main clinical features of dementia with LB

Answer 11

• fluctuating cognition with variations in attention
• visual hallucinations

Later: Parkinsonism features shuffling gait, flexed posture (different to Parkinson’s where these come first)

Question 12

Pathophysiology of fronto-temporal dementia

Answer 12

2nd commonest cause early- onset
Peak 55-65yrs
Atrophy of frontal and temporal lobes

Question 13

Presenting complaints of fronto-temporal dementia

Answer 13

• 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

Question 14

Risk factors for vascular dementia and cause

Answer 14

Hypertension
Smoking diabetes
Vascular disease

Due to cerebrovascular disease (ischaemia or haemorrhagic)

Question 15

Presenting complaint of vascular dementia

Answer 15

Step wise decline in cognitive performance in vascular dementia

Peaks and gradual overall decline

Question 16

Pathophysiology of AIDS- dementia complex

Answer 16

Increased prevalence
HIV infected macrophages enter brain -> indirect neuronal damage
Insidious onset but rapid progression

Question 17

Presenting complaints of AIdS- dementia and treatment

Answer 17

Cognitive impairment 
Psychomotor retardation 
Tremor
Ataxia
Dysarthria
Incontinence

✅antivirals

Question 18

Common investigations of dementia cases

Answer 18

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

Question 19

Management for dementia

Answer 19

Bio- psycho social model 
Mobility problems, 
daily activities, 
Learn new skills ability,
Financial problems

Question 20

What is delirium?

Answer 20

Confusion assessment method:

• acute onset of altered mental status and fluctuating course
• inattention
• disordered thinking
• altered level of consciousness (main difference with dementia)

Question 21

What are the two types of delirium?

Answer 21

Hyperactive and hypoactive

Most the time alternate between the two

Question 22

Causes of delirium

Answer 22

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

Question 23

Believed cause of delirium

Answer 23

Complex

Cholinergic- dopaminergic imbalance

Question 24

Investigations of delirium

Answer 24

FBC
U&Es
ESR/ CRP
TFTs
LFTs
Random blood sugars
Blood culture - sepsis

Urine dip
Oxygen sats

CXR
CT head

Review drug history

Question 25

Treatment of delirium

Answer 25

Underlying cause
Calm environment
Rehydration
Haloperidol (only if essential)

Question 26

What are the main differences between dementia and delirium?

Answer 26

Dementia: slow onset, steady decline, hallucinations rare, speech slow, normal GCS, clear consciousness

Delirium: opposite. Speech slow or fast, fluctuant course

Question 27

How to assess unconscious patient

Answer 27

Check breathing/ central pulse

Lie on left side

Call help

Sterna rub or trapezius squeeze or fingernails pressure test

Ensure stable

Assess Glasgow coma score (eyes, verbal, motor response)