CT 4 - The Patient With Memory Problems Or Confusion Flashcards
what is dementia
Disturbance of multiple higher cortical functioning e.g memory, thinking, language, judgement
May be accompanied/preceded by deterioration in emotional control, social behaviour or motivation
Impairment sufficient to impact on daily living functioning
Irreversible in most cases
what are differential diagnoses for dementia
ageing
MCI
delirium
depression
amnesic episode
reversible causes:
- space occupying lesions
-alcohol abuse
-medication se
-thyroid problems
- NPH
-Vitamin deficiencies B12 + folate
what is classed as MCI
intermediate stage between senescence related brain changes and dementia
there may be subtle impairment in at least one of memory, language, visuospatial skills, planning or judgement but their ADLs will not be affected
what investigations are carried out in a dementia screen
- thorough history and mental ability tests (like GP assessment of cognition, short and long memory tests, tests for concentration and attention spans, tests for language and communications skills + tests for awareness of time and place.
- blood tests (FBC, U+Es, LFTs, thyroid function, HbA1c, B12 +B9, syphilis
- brain scans = MRI, CT, PET or SPECT
*SPect = look for patterns of hypoperfusion in vascular dementia
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For alzheimers disease what will be seen on scans
medial temporal atrophy
hippocampal atrophy
how does normal ageing impact individuals
normal ageing brain will experience reduced attention, reduced processing in working memory, reduced ability to encode new material into long-term memory, and reduced efficiency of retrieval
what proportion of those with MCI progress to dementia
15%
causes of MCI
early dementia, physical health problems (e.g. COPD, heart failure etc, which
also affect cognitive function), medication side effects (e.g. anticholinergic or sedative drugs), and
other mental health problems (e.g. anxiety, depression etc)
what is delirium
disturbance of
-consciousness (i.e. sleep-wake cycle),
-cognitive function (i.e. confusion),
- perception (i.e. hallucinations, delusions, illusions etc), and
-affect (i.e. mood changes)
what are the three types of delirium
1) hyperactive (motor agitation, restlessness and aggressiveness)
2) hypoactive (motor retardation, apathy + slowed speech)
3) Mixed
How to distinguish delirium from dementia
- delirium - rapid onset, + fluctuates (NB may be LBD)
more prominent and psychotic symptoms (NB may be seen in LBD)
abnormal motor activity
what are some causes of delirium
medication (e.g. anticholinergics, anti-muscarinics (i.e. bladder
stabilisers), tricyclics, anti-Parkinsonian agents etc), acute infections (e.g. chest, urine etc),
constipation, hypoxia (so cardio-reps causes), and dehydration and electrolyte abnormalities (e.g.
hyponatremia, commonly caused by diuretics and antidepressants
diabetic complications, intracranial causes (e.g. head injuries, encephalitis,
tumours, raised ICP etc), metabolic causes (e.g. anaemia, hepatic encephalopathy, uraemia, cardiac
failure, hypothermia etc), and endocrine causes (e.g. pituitary, thyroid, parathyroid, adrenal etc
risk factors for delirium
age, cerebral compromise (e.g. dementia, Parkinson’s, MS etc),
chronic medical conditions, renal impairment, functional disability (i.e. being in a wheelchair, being
paralysed etc), previous delirium, sensory impairment, poly-pharmacy, and being in an unfamiliar/new
environment
Describe the community, residential and nursing home support available for
patients suffering from psychiatric disorders in old age (HS)
Community mental health teams (CMHT) support those with mental health problems in the
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Social care gives support to carry out day to day tasks that you are finding difficult. It includes help
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Residential care is for patients unable to cope in their own home. Examples include hostels (short
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The Crisis Resolution and Home Treatment team (CRHT) can support you through a crisis at
community and also their carers. The team may include community psychiatric nurses,
psychologists, occupational therapists, counsellors, community support workers, social workers, and
a care coordinator
with managing money, improving relationships, transport to attend appointments, or assistance with
benefits and housing applications.
term), residential care homes (higher level of support for people with severe mental health problems),
therapeutic communities (group or individual therapy as part of rehabilitation programs), and
supported housing schemes (enable you to live independently, in furnished accommodation, with the
back up of a support worker in case you need extra help)
home. Other alternatives for a crisis include an emergency appointment with a doctor, the
Samaritans, the CMHT, and A&E
Recognise and describe the initial investigation and treatment for delirium (acute
confusional state) (ALS)
Identifying and treating the precipitating causes and exacerbating factors is important (e.g.
hydration, nutrition, elimination, pain control etc). Also, providing environmental and supportive
measure is key (e.g. education of those interacting with the patient, making the environment safe with
adequate lighting, reducing unnecessary noise, using clocks and calendars etc)
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You should avoid sedation unless the patient is severely agitated, or if it is necessary to minimise risk
to patient or to facilitate investigation/treatment. In this case, use a single medication, start at a low
dose and titrate until you see effects (e.g. oral haloperidol up to 6mg daily, oral lorazepam up to 4mg
daily, oral risperidone up to 6mg daily etc). Benzodiazepines tend to worsen delirium, with the
exception of alcohol withdrawal
Give examples of the effects of dementia on carers, and models of support
available to carers (HS)
Carers are anyone who cares, unpaid, for a friend or family member who due to illness, disability, a
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Carers may have to give up work, which can lead to financial problems. It can be a constant battle to
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Carers can get physically exhausted (i.e. getting up several times in the night, caring throughout the
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Carers can also get emotionally exhausted, with the effects of seeing someone you care about
mental health problem, or an addiction cannot cope without their support
access help for themselves and the person they care for
day, doing manual work, juggling caring and looking after other members of the family, holding down
another job etc)
experiencing pain, distress, discomfort. This can lead to stress, depression or other mental health
issues for the carer. The carer’s own relationships with partner/family might be affected
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Carers may be isolated as they can’t leave the house, they may find it hard to make or sustain
friendships, and they may have difficulty keeping up with interests and activities they previously
enjoyed
*
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Young carers can find it hard to go to school/college/university and keep up with work. They may
have little time for ‘being a child’ and playing or socialising etc, which can lead to bullying. Caring can
also mean putting your career on hold, and not reaching your full potential
Support for carers can include education about dementia, training to manage common problems,
and providing respite care (e.g. temporary care provided to allow for short breaks)
what are the five principles of the MCA 2005
Presumption of capacity
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A person is not to be treated as unable to make a decision unless all the steps to help them do
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so have been taken without success
A right to make unwise decisions
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Best interest
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Least restrictive option
what is deprivation of liberty
when you are kept on a locked ward or in a locked room, or you are not free to go anywhere without permission or close supervision, and you are continuously supervised. This
may happen if you need to go into a care home or hospital to get care or treatment, but you don’t
have the capacity to make decisions about this yourself.
Assess the possibility of depression in older people who appear to have dementia
(ALS, CSR)
15% of over 65s in the community are depressed at any time, with 30% in hospitals. Depression is commonly diagnosed in the early stages of dementia, but may present at any stage. Depression is
more common in those with vascular or Parkinsonian dementia, and is also common in carers of
dementia
Triggers of depression are bereavement, social isolation, poverty, physical illness, chronic pain, and having dementia (as people find it harder to remember things, and may be more confused or withdrawn)
what is korsakoff’s syndrome
- anterograde amnesia
retrograde amnesia
confabulation
impairment of recent memory (anterograde amnesia,
which is trouble making new memories), and some impairment of distant memory (retrograde
amnesia, which is forgetting memories formed before the event that caused the amnesia). There may
also be confabulation, which is the creation of false memories
however immediate recall is preserved and other cognition is usually well
causes of amnesia
alcohol (which can cause vitamin B1 deficiency, leading to Korsakoff’s
syndrome), heavy drug use, toxins (e.g. lead, mercury, carbon monoxide, insecticides etc), head
trauma, tumours, strokes, cerebrovascular disease, and infections (e.g. post-meningitis, TB etc)
Describe the effects of ageing on presentation of mental illness, on the
pharmacokinetics of drug treatments and the implications for prescribing (ALS)
Older people with depression tend to report more physical symptoms than emotional symptoms i.e. fainting, dizziness, pain, weakness, heavy limbs, lump in the throat, constipation etc). They also
tend to report hypochondriasis more, as well as more slowing down of emotional reactions. Finally,
older people tend to show more psychotic features (i.e. delusions, hallucinations etc)
If you are in doubt over whether an older person has dementia or depression, trial an antidepressant for 6 weeks, and then afterwards investigate for dementia if cognitive problems
persist
For dementia (where there are changes in mood and behaviour), the first line choice is an SSRI (e.g. sertraline) or mirtazapine. Mirtazapine is useful to aid sleep and increase appetite. You should start
on a low dose, and then gradually increase over 1 or 2 weeks (in older people, antidepressants
should be trialed for longer, so 2-3 months, and there should be a longer period of maintenance
treatment after recovery)
The main side effects are hyponatremia, nausea, insomnia, and an increased risk of gastric bleeding. Venlafaxine (a SNRI) can cause possible QT prolongation, while citalopram (an SSRI) much more
commonly affects the QT interval
With any psychological medication, start on a low dose, and slowly increase. Avoid augmentation, and do not treat side effects with additional medications. Overall, it is best to avoid alpha
adrenoreceptor blockers, and drugs with anticholinergic side effects (e.g. anorexia, blurred vision,
constipation, sedation, urinary retention, dry eyes and mouth), as there is possible increased risk of
dementia and increased risk of delirium
Antipsychotics should also be avoided in people with dementia, as they increase mortality. Sedative medications should be avoided, liver enzyme inhibitors should be avoided (e.g. erythromycin,
allopurinol, omeprazole etc), and avoid using risperidone or olanzapine to treat behavioural
symptoms of dementia, as they increase stroke risk
what are the causes of dementia
Alzheimer’s disease (50-60%)
Vascular dementia (20-30%)
Lewy Body dementia (10-15%)
Fronto-temporal dementia (2-5%)
Alcohol (up to 10%)
Other causes inc. Parkinsons disease,
Huntington’s, CJD, HIV, MS etc.
features of Alzheimer’s
Memory- early episodic changes
Language
Motor Skills (praxis)
Recognition Skills (gnosis)
ADL
Personality e.g. apathy, irritability
Can also develop psychotic symptoms, gait disturbances, seizures, extra pyramidal symptoms etc.
managed with acetylcholinesterase inhibitors such as donepezil and rivastigmine
memantine (NMDA antagonist)
vascular dementia
Due to cerebral ischemia/Infarction
Infarction sudden step wise deterioration
Deficits dependent on damaged region
May co-exist with AD
May co-exist with small vessel disease
impairments in:
- focal neurological (vision, sensory + motor)
- attention + concentration
- seizures
-memory
- gait
- speech
features of small vessel disease
Insidious onset, gradual progression
apathy,
slowness of thought,
Problems with executive functioning
reduced attention
relative preservation of higher cortical functions
(e.g gnosis, praxis, visuospatial etc)
Esp. subcortical and periventricular white matter
(Binswangers)
May be problems with mobility/gait
features of LBD
deposition of alpha synuclein/lewy bodies in substantia nigra, paralimbic and neocortical areas
- associated with parkinsons disease
progressive cognitive impairment which typically occurs before parkinsonism symptoms.
(In parkinson’s disease motor symptoms begin a year before cognitive decline)
- cognition in this form of dementia may fluctuate which is unlike other forms of dementia
- visual hallucinations also seen
diagnosis:
- SPECT
features of FTD
Primary Progressive aphasia and semantic dementia
Stereotypical, repetitive and compulsive behaviour
Apathy, withdrawal, self neglect
Dis-inhibition, impaired judgement e.g. overspending, socially inappropriate, criminal, sexualised behaviours
Emotional blunting, shallow affect etc
Abnormal eating, hyper-orality etc
Language problems
Relative preservation of memory, visuo spatial functioning in early stages.
Management of Dementia
psychosocial
Diagnosis, counselling, education etc
- Identification of strengths and weaknesses
- Targeting interventions, social stimulation, management of mood etc
- Lifestyle changes
- Planning for the future, practical, financial etc
- Cognitive Stimulation Therapy
Reminiscence
Carer support and education
Social and home care services
medical management of dementia
Optimising physical health and medication- including stopping unnecessary medication, eyesight, hearing, mobility etc
Modification of risk factors
e.g. cardio/cerebrovascular
Lifestyle advice
Drug management
- Symptomatic treatments (e.g.
antidepressants, anti-psychotics etc)
- Disease modifying treatments e.g. AchI’s, memantine
