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Geriatrics > Delerium + Dementia > Flashcards

Delerium + Dementia Flashcards

1
Q

What is cognition

A

Mental action of acquiring and understanding knowledge through experience and senses

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2
Q

What is important in the history of cognitive impairment

A

Onset - when and how rapid
Course - fluctuates / progressive / baseline
Associated features - functional loss / other illness

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3
Q

What are the features of delirium

A

ACUTE change in mental state
FLUCTUANT - worse night
Disturbed consciousness - common
- Hypo or hyper
Change in cognition - concentration / attention / short- memory
Disorientation - time and place NOT person
Short attention span where as dementia normal
Disturbance of sleep / wake
Disturbed psychomotor - early on where as dementia late
Emotional - low mood
Change in personality
Delusions
Hallucinations - usually visual

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4
Q

What are the types of delerium

A

Hyperactive = restless / agitated
Hypoactive = withdrawn + sleepy
More at risk of complications - HAP / pressure sore / mobility as don’t respond
Mixed

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5
Q

What are the RF for delerium

A 
Age >65 
Dementia / previous cognitive impairment 
Frailty
Polypharmacy
Operation - hip fracture
Sensory deficit 
Dehydration
Severly ill acute illness = common in young
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6
Q

How can cause delerium

A 
Infection - not always UTI 
Constipation -> + retnetion
DRUGS 
Dehydration 
Surgery / post GA 
Pain - often undertreated
Metabolic 
Biochemical - hypoglycaemia / hypercalcaemia 
B12 / thyroid
AKI
Hypoxia
Alcohol withdrawl / substance withdrawal 
Sleep disturbance
Brain injury - stroke / tumour / bleed
Change in environment if particularly at risk
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7
Q

How do you Dx delerium / what should you do if you come across confused patient

A

Screen 4AT in all >65 esp if sleepy / drowsy / confused
or if acute change
TIME BUNDLE / delerium pathway if 4AT score high to look for cause
Full Hx + exam inc neurological
Stroke can present solely as delerium
NEWS - sort out any issues that have gone off
Bladder and bowels - do PR or bladder scan
Assess hydration
Any pain
MED review
INFECTION - sepsis 6 / urine dip
Blood - FBC, U+E, Ca, BG, CRP
Blood culture
ECG

Consider 
Bone profile
CK 
Urine tox screen 
CT / CXR / EEG / LP
Ca, B12, folate, TFT as can cause confusio
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8
Q

What is important to remember in managing delirium / dementia

A

Does patient have capacity
Does patient have welfare POA or guardian
Involve MDT

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9
Q

What does 4AT take into consideration

A

Alertness
AMT 4 - age, DOB, name of hospital, year
Attention - months backwar
Acute or fluctuating over last 2 week - collateral

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10
Q

How do you treat

A

Treat cause
TIME if 4AT high to look for cause
Non-pharmacological
Pharmacological

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11
Q

What are non-pharmacological measures

A 
Reorientate
Reassure
Phone family to settle
Early mobility
Correct sensory
Normalise sleep wake 
Ensure conitnuity of care
Avoid catheter / invasive procedure
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12
Q

What are pharmacological measures

A

Correct news
Stool chart / laxatives
Fluid / Ax
Stop bad drugs - anti-cholinergic / sedatives
Anti-psychotic if severe distress but only on senior advice
- Quetiapine / haloperidol 0.5mg 1st line - call senior
Benzo only useful in alcohol withdrawl or Parkinsonism as can’t have anti-psychotic
- Lorazapam = 1st line as short half-life

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13
Q

What is the follow up for delerium

A

Primary care
Follow up cognitive assessment with GP - always ask for in discharge
Predispose to developing dementia

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14
Q

What is dementia

A

Acquired decline in memory and other cognitive function in an alert person >6 months causing functional impairment
- i.e. forget tablet / inability to use phone / difficult ADL
Affects other domains - social, memory, executive, language, complex attention
Loss of acquired skills
Change in mood / personality
NOT ACUTE
Interferes socially and occupational

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15
Q

What are the different types of dementia

A 
Alzheimer's 
Dementia with Lewy Body 
Vascular
Fronto-temporal 
Mixed
Rare non-reversible - Huntington / CJD / HIV / MS
Reversible causes
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16
Q

How do you Dx dementia

A

History + collateral
Examination - neuro exam
Bloods
- Metabolic screen / B12 / TSH
MMSE / MOCA = screen but not diagnostic
Functional ability = more important than a score
Exclude differentials / reversible causes
Brain scan - MRI / SPECT
- Brain imaging required prior to Dx of dementia
Neuropsychology

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17
Q

What are reversible causes of dementia

What are other causes of dementia that are non-reversible

A 
B12 / folate deficiency 
Hypothyroid
Alcohol withdrawal
Metabolic - Hypercalcaemia
SLE
Normal pressure hydrocephalus 
Syphillis
Anti-cholinergic drugs
Depression 
Delirium 
Brain haemorrhage / lesion
Wilson's disease
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18
Q

Why should you correct B12 first

A

RIsk of cord degeneration

Involved in DNA repair

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19
Q

How is depression differentiated from dementia

A 
Short history
Rapid onset 
Weight loss / sleep affected
Worried about memory
Reluctance to take test 
Variable MMSE 
Global loss compared to recent in dementia
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20
Q

What can GP screen for

A 
FBC, U+E, Ca, glucose, LFT
MSSU 
Vit B12 / folate / thiamine 
Copper 
TFT
AutoAb
Syphillis / HIV / serology if indicated
ECG
Neuro exam
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21
Q

WHat can secondary care do

A 
Neuroimaging - subdural / hydrocephalus / tumour 
CT / MRI
SPECT
EEG if indicated 
Genetic biopsy for CJD
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22
Q

How does Alzheimers present

A 
Slow insidious onset
Loss of recent memory / short term first 
Progressive functional decline 
Disorientation time and place 
Language impairment 
5A's - aphasia, apraxia, alexia, agnosia, acalculi 
Lack of insight
Apathy 
Behaviour and mood change occur late
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23
Q

What are RF for Alzheimers

A 
Age
FH
Down's
Decrease cognitive / delirium
Hypothyroid
Trauma
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24
Q

What are characteristic changes

A

Hippocampal atrophy
Medial temporal lobe atrophy
Accumulation of B-amyloid

Mendolian genetic cause is rare - possibly in the young ?

25
Q

How does vascular dementia present

A

Mini small strokes in brain
Step wise decline
Excecutive dysfunction - mood / falls / incontinence / seizure predominates
Gait problems
Memory spared till late
KNown vascular RF - type II DM, AF, IHD, PVD

26
Q

What is main stay of Rx for vascular

A

Can USS carotid
MRI shows multiple white matter + lacunar lesion

2 prevention
BP and diabetic control
Statin and aspirin
Symptom relief

27
Q

How does Lewy bodies present

A 
Fluctuating cognitive impairment
Visual hallucination
Early falls 
Parkinsonism - brady / stiff
Autonomic / psych / REM / aggression

LBD if <1 and memory goes
Parkinson’s if Sx >1 year before memory decline

28
Q

How do you Dx Lewy bodies and what causes

A

Clinical
DATSPECT = abnormal
Deposits of alpha synuclein in SN
Cerebral atrophy particularly frontal lobe

29
Q

What should you avoid in Lewy Body

A

Anti-psychotics / neuroleptics

30
Q

How does fronto-temporal dementia present

A

Early age of onset <65
AD
Insidious
Picks disease - frontotemporal atrophy + pronounced gyro seen on MRI
- Personality
- Disinhibition
- Increased appetite
Behaviour change - emotional blunting + apathy
Language difficulties - aphasia
Memory + visuospatial not affected early on
Lack insight

31
Q

What is not recommended in fronto-temporal

A

Cholinesterase inhibitiors
No Rx
6 year prognosis

32
Q

What are rare causes of demenita

A

Huntington - abnormal movement
CJD - rapidly progressive + myoclonus
HIV

33
Q

What is the non-pharm management of dementia

A 
Support
Cognitive stimulation
CBT 
Exercise
Music / light therapy
Orientation therapy
Melatonin for sleep ? - only short-term
Anti-Depressant - SSRI 
Anti-psychotic may be needed for short term
34
Q

What are pharmacological measures

A

Cholinesterase inhibitors for mild-moderate
Memantine = 2nd line (NMDA antagonist)
Anti Glutaminergic for Picks disease
Anti-psychotics if severe for non-cognitive Sx such as psychosis but increase risk of stroke / TIA
Use atypical in Lewybody
L-dopa for Parkinson Sx of Lewybody

35
Q

What do cholinesterase inhibitors do

A

Delay breakdown of Ach
Donepezil - Main use in Alzheimer / 1st line ALL
Galantamine - mixed
Rivastigmine - Lewy Body

36
Q

Whar are the SE

A 
GI - +V+D
Headache
Cardiac rhythm - syncope
Faituqe
Insomnia
Cramps
DOn't stop disease progression
Improve non-cognitive symptoms so less carer stress / improved ADL
37
Q

When are anti-psychotics indicated
Why not
When would you never use

A 
Specialist
Depression / psychosis / aggression
Avoid if possible as increased risk of stroke / TIA
Anti-depressants not indicated
DOn't use in Lewybody
38
Q

What is differences between delirium and dementia

A

Delerium

  • Inattention
  • Distracted
  • Disordered thinking
  • Early psychomotor
  • Acute and flucutaiton
  • Disorientated time and place (person in dementia)
39
Q

What should you do before assessing capacity

A

Correct sensory
SALT
Time
Just because decision is unwise doesn’t mean lack capacity

40
Q

What if the person has mental disorder

A

Mental Health Act

41
Q

WHat 5 things do have capacity

A 
Make decision - benefits /  risk
Act decision 
Communicate
Understand
Retain memory
42
Q

What is POA

A

Granted by person when have capacity
Continuing = financial
Welfare = healthcare

43
Q

What is guardianship

A

Granted AFTER person lost capacity

Court decision

44
Q

What is guardianship intervention order

A

For one off decisions

45
Q

Patinet off legs and confused
Febrile
What do you do

A

History
DH
Bloods - high CRP, WCC + urea, creatinine high

46
Q

Most likely diagnosis

A

Delerium secondary to Infection
Drug
Dehydration - renal function / diuretic / high urea
Constipation 2 opiates

47
Q

What should you always do

A

PR

48
Q

Ddx delerium

A 
Dementia
Anxiety
Epilepsy - consider EEG
Schizophrenia - rare if no HX
Stroke
49
Q

When are cholinesterase inhibitors CI

A

Bradycardia

Fronto-temporal

50
Q

What do you give for Parkinson’s Sx

A

L-dopa

51
Q

What drugs can cause confusion

A

OPiates
Anti-cholinergic
Anti-depressant
Parkinson drugs

52
Q

What is mild, mod, severe MMSE score

A

Mild - 21-30
Mod - 10-20
Severe - <10

53
Q

What are behaviour / neuro-psychatric disruption Sx in dementia

A 
Agitation
Psychosis
Depression 
Disinhibited
Altered circadian rhythm 
Anxiety
54
Q

How do you Rx

A 
Adapt environment
Look for aggravating factors
Treat trigger
Anti-psychotic as last attempt 
- Haloperidol = 1st line
55
Q

What causes Weirnecke’s encephalopathy

A

Thiamine deficiency - common in alcoholics
Persistent vomiting
Stomach cancer
Diet

56
Q

How does it present

A 
Confusion
Opthalmoplegia 
Ataxia 
Nystagmus
Peripheral sensory neuropathy
57
Q

How do you Dx

A

MRI

58
Q

How do you Rx

A

Thiamine as paprinex

Give in hospital if at risk

59
Q

What can it lead to

A

Korsakoff’s

  • Antegrade amnesia
  • Retrograde amnesia

Geriatrics (8 decks)

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