Delerium + Dementia Flashcards
What is cognition
Mental action of acquiring and understanding knowledge through experience and senses
What is important in the history of cognitive impairment
Onset - when and how rapid
Course - fluctuates / progressive / baseline
Associated features - functional loss / other illness
What are the features of delirium
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
What are the types of delerium
Hyperactive = restless / agitated
Hypoactive = withdrawn + sleepy
More at risk of complications - HAP / pressure sore / mobility as don’t respond
Mixed
What are the RF for delerium
Age >65 Dementia / previous cognitive impairment Frailty Polypharmacy Operation - hip fracture Sensory deficit Dehydration Severly ill acute illness = common in young
How can cause delerium
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
How do you Dx delerium / what should you do if you come across confused patient
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
What is important to remember in managing delirium / dementia
Does patient have capacity
Does patient have welfare POA or guardian
Involve MDT
What does 4AT take into consideration
Alertness
AMT 4 - age, DOB, name of hospital, year
Attention - months backwar
Acute or fluctuating over last 2 week - collateral
How do you treat
Treat cause
TIME if 4AT high to look for cause
Non-pharmacological
Pharmacological
What are non-pharmacological measures
Reorientate Reassure Phone family to settle Early mobility Correct sensory Normalise sleep wake Ensure conitnuity of care Avoid catheter / invasive procedure
What are pharmacological measures
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
What is the follow up for delerium
Primary care
Follow up cognitive assessment with GP - always ask for in discharge
Predispose to developing dementia
What is dementia
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
What are the different types of dementia
Alzheimer's Dementia with Lewy Body Vascular Fronto-temporal Mixed Rare non-reversible - Huntington / CJD / HIV / MS Reversible causes
How do you Dx dementia
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
What are reversible causes of dementia
What are other causes of dementia that are non-reversible
B12 / folate deficiency Hypothyroid Alcohol withdrawal Metabolic - Hypercalcaemia SLE Normal pressure hydrocephalus Syphillis Anti-cholinergic drugs Depression Delirium Brain haemorrhage / lesion Wilson's disease
Why should you correct B12 first
RIsk of cord degeneration
Involved in DNA repair
How is depression differentiated from dementia
Short history Rapid onset Weight loss / sleep affected Worried about memory Reluctance to take test Variable MMSE Global loss compared to recent in dementia
What can GP screen for
FBC, U+E, Ca, glucose, LFT MSSU Vit B12 / folate / thiamine Copper TFT AutoAb Syphillis / HIV / serology if indicated ECG Neuro exam
WHat can secondary care do
Neuroimaging - subdural / hydrocephalus / tumour CT / MRI SPECT EEG if indicated Genetic biopsy for CJD
How does Alzheimers present
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
What are RF for Alzheimers
Age FH Down's Decrease cognitive / delirium Hypothyroid Trauma
What are characteristic changes
Hippocampal atrophy
Medial temporal lobe atrophy
Accumulation of B-amyloid
Mendolian genetic cause is rare - possibly in the young ?
How does vascular dementia present
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
What is main stay of Rx for vascular
Can USS carotid
MRI shows multiple white matter + lacunar lesion
2 prevention
BP and diabetic control
Statin and aspirin
Symptom relief
How does Lewy bodies present
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
How do you Dx Lewy bodies and what causes
Clinical
DATSPECT = abnormal
Deposits of alpha synuclein in SN
Cerebral atrophy particularly frontal lobe
What should you avoid in Lewy Body
Anti-psychotics / neuroleptics
How does fronto-temporal dementia present
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
What is not recommended in fronto-temporal
Cholinesterase inhibitiors
No Rx
6 year prognosis
What are rare causes of demenita
Huntington - abnormal movement
CJD - rapidly progressive + myoclonus
HIV
What is the non-pharm management of dementia
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
What are pharmacological measures
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
What do cholinesterase inhibitors do
Delay breakdown of Ach
Donepezil - Main use in Alzheimer / 1st line ALL
Galantamine - mixed
Rivastigmine - Lewy Body
Whar are the SE
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
When are anti-psychotics indicated
Why not
When would you never use
Specialist Depression / psychosis / aggression Avoid if possible as increased risk of stroke / TIA Anti-depressants not indicated DOn't use in Lewybody
What is differences between delirium and dementia
Delerium
- Inattention
- Distracted
- Disordered thinking
- Early psychomotor
- Acute and flucutaiton
- Disorientated time and place (person in dementia)
What should you do before assessing capacity
Correct sensory
SALT
Time
Just because decision is unwise doesn’t mean lack capacity
What if the person has mental disorder
Mental Health Act
WHat 5 things do have capacity
Make decision - benefits / risk Act decision Communicate Understand Retain memory
What is POA
Granted by person when have capacity
Continuing = financial
Welfare = healthcare
What is guardianship
Granted AFTER person lost capacity
Court decision
What is guardianship intervention order
For one off decisions
Patinet off legs and confused
Febrile
What do you do
History
DH
Bloods - high CRP, WCC + urea, creatinine high
Most likely diagnosis
Delerium secondary to Infection
Drug
Dehydration - renal function / diuretic / high urea
Constipation 2 opiates
What should you always do
PR
Ddx delerium
Dementia Anxiety Epilepsy - consider EEG Schizophrenia - rare if no HX Stroke
When are cholinesterase inhibitors CI
Bradycardia
Fronto-temporal
What do you give for Parkinson’s Sx
L-dopa
What drugs can cause confusion
OPiates
Anti-cholinergic
Anti-depressant
Parkinson drugs
What is mild, mod, severe MMSE score
Mild - 21-30
Mod - 10-20
Severe - <10
What are behaviour / neuro-psychatric disruption Sx in dementia
Agitation Psychosis Depression Disinhibited Altered circadian rhythm Anxiety
How do you Rx
Adapt environment Look for aggravating factors Treat trigger Anti-psychotic as last attempt - Haloperidol = 1st line
What causes Weirnecke’s encephalopathy
Thiamine deficiency - common in alcoholics
Persistent vomiting
Stomach cancer
Diet
How does it present
Confusion Opthalmoplegia Ataxia Nystagmus Peripheral sensory neuropathy
How do you Dx
MRI
How do you Rx
Thiamine as paprinex
Give in hospital if at risk
What can it lead to
Korsakoff’s
- Antegrade amnesia
- Retrograde amnesia
