Delerium + Dementia Flashcards by Eilidh Seaton

What is cognition

Mental action of acquiring and understanding knowledge through experience and senses

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What is important in the history of cognitive impairment

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

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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

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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Hypoactive = withdrawn + sleepy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

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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

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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

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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

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What is important to remember in managing delirium / dementia

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

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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

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How do you treat

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

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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

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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

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What is the follow up for delerium

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

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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

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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

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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

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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

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Why should you correct B12 first

RIsk of cord degeneration

Involved in DNA repair

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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

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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

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WHat can secondary care do

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

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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

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What are RF for Alzheimers

Age
FH
Down's
Decrease cognitive / delirium
Hypothyroid
Trauma

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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

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