Delerium/dementia Flashcards
What is dementia
Umbrella term for a syndrome of impairment in memory or thinking severe enough to interfere w/ ADL, work, or relationships
AKA: changes in memory or thinking over time
Examples of cognitive deficits in dementia are
Memory Apraxia (motor activities) Aphasia (speech) Agnosia (fail to recognize objects) Disturbed executive function (think, plan, organize)
DSM5 for dementia is
- Significant cognitive decline in 1+ domain (learning and memory, language, executive fxn, complex attention, perceptual motor, social cognition)
- Cognitive deficits interfere w/ independence (assistance needed for IADL)
- Cognitive deficits occur when NOT delirious
- Cognitive deficits not better explained by another mental d/o
What is the MMSE
Max score is 30, takes 7-10 min
<24 is abnormal
(<24 for education= abn for college education)
<21= increased odds of dementia
Dementia is
Progressive and slow to present
disabling and fatal
Delirium is also known as
ACUTE confusional state acute mental status change AMS organic brain syndrome (reversible dementia) Toxic or metabolic encephalopathy
What morbidity is associated with delirium
10x increased risk of death in hospital
3-5x increase risk of nosocomial complications, long stay, nursing home placement
Poor functionsl recovery and increased risk of death up to 2 years sp discharge
Persistence of delirium (poor long term outcome)
Who recognized delirium
Nurses more than docs (<50% vs 20%)
What is DSM5 for delirium
- Disturbance in attention and awareness
- Develops over short period of time (hr-day), change from baseline, fluctuates thru day
- disturbance in cognition (memory, disorientation, language, perception)
- Not 2/2 neurocognitive d/o
- Evidence that disturbance is directly 2/2 another medical condition (toxin, intoxicated, etc.)
Delirium is more likely to have this symptom than dementia
Hallucinations
How do you diagnose delirium
DSM5 is difficult, so most use CAM (confusion assessment method)
Clinically more useful with >95% Sn/Sp
What is the CAM
- Acute change in mental status and fluctuating course
- Inattention
- Disorganized thinking
- ALOC
- Need 1 and 2, and 3 or 4
What is the delerium spectrum
Hyperactive or agitated delirium Hypoactive delirium (MC and worst prognosis) Mixed
What is the pathologic disturbance in delirium
Ach is needed for cognitive process. Cholinergic deficiency can cause delirium
-Anticholinergic drug OD (high serum anticholinergic activity), or high anti-Ach levels if not even taking anti-chol drugs
How do you reverse anticholinergic drug OD
Physostigmine!
Delirium is associated with what physiologic changes
Increased CRP, IL-1B, and TNF
Non-specific markers of inflammation
What can inflammation do
Breakdown BBB and allow toxic meds and cytokines into CNS
Predisposing factors of delirium include
Advanced age Dementia Impaired ADL Comorbidities Hx of EtOH abuse Male Sensory impairment
Precipitating factors of delirium are
Acute cardiac event acute pulmonary event bed rest drug withdrawal fecal impaction fluid/lyte imbalance indwelling cath infections (resp/urinary) meds restraints severe anemia uncontrolled pain urinary retention
Pre-operative RF for Pst-op delirium include
70+ Cognitive impairment Physical funcitonal impairment Hx EtOH abuse Abn serum chemistries ntrathoracic and aortic aneurysm surgery (3+ RF has 50% increased risk) (cardiac surgery/AAA repair/ hip Fx repair have highest risk)
Keys to preventing post-op delirium include
Limit sedation
Provide adequate analgesia (delirium is associated with post-op pain AND use of benzos and opioids)
Peak onset is 2nd post-op day
Post-op delirium is associated with
Post-op pain
Post-op anemia
Use of benzos and opioids (meperidine)
In your delirium history, focus on
Time course! med review (including OTC and alcohol)
Delirium PE should include
vitals
O2 sat
Gen medical eval
neuro and MSE
