Delirium and Dementia

Question 1

Define delirium

Answer 1

• ‘Acute, transient and reversible state of confusion, usually the result of other organic processes (infection, drugs, dehydration) – onset acute and cognition of patient fluctuant over a short period of time’

Question 2

Outline hyperactive delirium

Answer 2

• Agitation
• Delusions
• Hallucinations
• Wandering
• Aggression

Question 3

Outline hypoactive delirium

Answer 3

• Lethargy
• Slowness with everyday tasks
• Excessive sleeping
• Inattention

Question 4

What are the precipitating factors of delirium?

Answer 4

• Pain
• Infection
• Nutrition
• Constipation
• Hydration
• Medication
• Environmental change

NB/environmental change + sensory impairment enough to cause delirium without deeper organic cause

Question 5

VULNERABILITY + NOXIOUS INSULT = ?

Answer 5

Delirium

Question 6

Outline the confusion screen for delirium

Answer 6

• FBC (infection/anaemia/malignancy)
• U+E (hyponatraemia/hypernatraemia)
• LFTs (liver failure with secondary encephalopathy)
• Coagulation/INR (intracranial bleeding)
• TFTs (hypothyroidism)
• Calcium (hypercalcaemia)
• B12 + folate
• Glucose
• Blood cultures
• Urinalysis (very common – positive dipstick without clinical signs NOT enough o diagnose UTI as cause of delirium (inc. WCC/supra-pubic tenderness/dysuria/offensive urine/positive urine culture needed)
• CT-head (bleeding/ischaemia/stroke/abscess) – if concerns of intracranial pathology
• CXR (if concern of lung pathology e.g. pneumonia/pulmonary oedema)

Question 7

List some screening tools for delirium

Answer 7

• Confusing screening assessment tool
• 4AT
• CAM variants

Question 8

How is delirium managed?

Answer 8

• Identify and treat underlying cause
• If non-pharmacological interventions and ineffective; first-line = haloperidol (oral, IV, IM) 0.5 mg (CONTRAINDICATED IN PARKINSON’S DISEASE!)

Question 9

What is dementia?

Answer 9

• A syndrome: a set of symptoms including memory loss, mood changes, and problems with communication and reasoning

- Memory impairment + impairment in any other domain (e.g. language/orientation/spatial ability)

- Changes reflect a decline

• Social and/or occupational functional capacity impaired

Question 11

List the causes of dementia in descending order

Answer 11

1. Alzheimer’s dementia
2. Vascular dementia
3. Mixed dementia
4. Lewy body dementia
5. Fronto-temporal dementia

Question 12

Outline mild cognitive impairment

Answer 12

• Cognitive decline greater than expected for an individual’s age and education level but does not interfere notably with ADLs
• MMSE ≥ 24/30
• Control vascular risk factors and treat depression

Question 13

What is Alzheimer’s disease?

Answer 13

• Neurodegenerative condition initially affecting temporal lobes but eventually spreading to adjacent and then all areas of the brain
• Microscopically: loss of synapses and neurons, intracellular proteins (neurofibrillary tangles) and extracellular proteins (amyloid plaques) develop in brain leading to death of brain cells
• Cholinergic neurones especially vulnerable

Question 14

What are the risk factors for Alzheimer’s disease?

Answer 14

• Age
• Genetics (ApoE4)
• Female
• Significant head trauma
• Family history
• Environment

Question 15

What is vascular dementia?

Answer 15

• Caused by vascular damage affecting small, medium, large vessels or combinations thereof
• Post-stroke dementia
• Small vessel disease
• Combination of the two

Question 16

What is the difference between the decline in function in Alzheimer’s and vascular dementia?

Answer 16

• Alzheimer’s is slow, progressive
• Vascular is slow and step-wise

Question 17

What are the risk factors for vascular dementia?

Answer 17

• Previous stroke
• Hypertension
• High cholesterol
• Diabetes
• Ischaemic heart disease
• Peripheral vascular disease
• Family history

Question 18

What is Lewy body dementia?

Answer 18

• Dementia plus…
• Parkinsonism
• Hallucinations
• Falls
• Fluctuation in cognition, alertness and attention vary
• REM sleep disorder
• Characterised by Lewy bodies (cytoplasmic inclusions) in brain
• Spectrum of LD disorders, overlap with PDD
• M = F
• More common > 65 years old

Question 19

What is fronto-temporal dementia?

Answer 19

• Caused by damage to frontal lobe and/or temporal parts of brain
• Rare (10% of cases of dementia)
• Affects younger people especially < 65 years
• M:F 66:34 %
• FH in 40–50% of patients
• Affects personality and speech

Question 20

How is Alzheimer’s disease treated pharmacologically?

Answer 20

• Cholinesterase inhibitors –
• Aricept (Donepezil)
• Exelon (Rivastigmine)
• Reminyl (Galantamine)

for mild-to-moderate disease; MMSE 10-26

• Peak efficacy at 3 months
• Some ADL and behaviour improvement
• Memantine (Ebixa) - for moderate-to-severe disease
• Neuroprotective agent
• Cognitive and functional improvement

Question 21

How is Alzheimer’s disease treated non-pharmacologically?

Answer 21

• Cognitive rehabilitation and training – build on memory skills a person still has or use compensatory aids – must focus on individual goals
• Cognitive Stimulation Therapy – in a group setting, based on theoretical concepts of reality
orientation training and cognitive stimulation
• Memory Groups
• Movement Programmes and psychomotor therapy
• Reminiscence – events from the past are discussed in one-on-one or group conversations