delirium

Question 1

How do you treat acute confusional states?

Answer 1

first instance it is important to identify the cause and treat it.

agitated then sedation may be necessary. Benzodiazepines may exacerbate confusion Haloperidol and Chlorpromazine may be better. It should first be discussed with a senior.

Non-pharmacological treatments include
nursing in a moderately lit room with repeated reassurance. See if a family member can stay with the patient as this may be reassuring to them and may avoid the need for sedatives. Making sure that the patient has their appropriate sensory aids (glasses, hearing aids etc.)

Question 2

How will you assess acute confusion on admission?

Answer 2

Cognitive function can be assessed quickly using the abbreviated mental test score (AMTS). The benefit of this test is that it can then be repeated during the admission, giving an indication of response to treatment.

The Confusion Assessment Method (CAM) is a specific set of 4 questions designed for the diagnosis of delirium.

Question 3

What factors predispose a patient to delirium?

Answer 3

Age >65

Dementia

Multiple co-morbidities

Visual and hearing impairment

Recent surgery

Polypharmacy

Drugs and alcohol dependence

Question 4

causes of dementia ?

Answer 4

Primary causes of Dementia:

Neurodegenerative conditions – Alzheimer’s disease; Parkinson’s plus syndromes; Frontotemporal dementia; CJD

Other: Vascular dementia; Normal Pressure Hydrocephalus*

Secondary cause of Dementia
Metabolic: folate, B12 and thiamine deficiency;
Hypothyroidism; Cushing’s syndrome; Wilson’s disease

Vascular: Cerebrovascular disease; subdural haematoma*

Neoplastic

Inflammatory

Infections: Syphilis; HIV

Question 5

How would you investigate a possible diagnosis of dementia?

Answer 5

In most cases the diagnosis of dementia is made in the memory clinic as an outpatient rather than in hospital. Your role as an acute medical SHO is recognising when dementia may be a possibility and making the appropriate investigations and referrals.

A CT head is important for anyone with a possible diagnosis of dementia to rule out reversible causes. On discharge from hospital, the discharge summary should include instructions to the GP to refer the patient to the memory clinic.

Question 6

What pharmacological treatment is available for the treatment of Alzheimer’s disease?

Answer 6

the three acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) as options for managing mild to moderate Alzheimer’s disease

memantine (an NMDA receptor antagonist) is in simple terms the ‘second-line’ treatment for Alzheimer’s, NICE recommend it is used :
moderate Alzheimer’s who are intolerant of, or have a contraindication to, acetylcholinesterase inhibitors
as an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe Alzheimer’s
monotherapy in severe Alzheimer’s