Delirium and Dementia Flashcards
Delerium
- Acute transient and global organic disorder of CNS functioning.
- Resulting in impaired consciousness, and attention.
Categories of RF of Delerium
HE IS NOT MAD
Hypoxia
Endocrine
Infection
Stroke
Nutrition
Other
Theatre
Metabolic
Abdominal
Alcohol
Drugs
Hypoxia RF for delirium
resp failure, MI, cardiac failure, pulmonary embolism
Endocrine associated delirium cause
hyperthyroid, hypothyroid, hyper or hypoglycaemia, cushings
Stroke associated delirium cause
stroke, raised ICP, intracranial haemorrhage or infection, space occupying lesions, head trauma, epilepsy
Nutrition related delirium cause
dec thiamine, nictotininc acid or B12
Other causes of delirium
pain, sensory deprivation, relocation, sleep deprivation
Theatre causes of delerium
anaesthesia, opiate analgesics, sepsis
Metabolic causes of delerium
hypoxia, electrolyte disturbance, hepatic impairment
Abdominal causes of delirium
faecal impaction, malnutrition, urinary retention or bladder catheterisation.
Symptoms of delirium
DELIRIUM
- Disordered thinking
- Euphoric, fearful, depressed or angry
- Language impaired
- Illusions, delusions
- Reversal of sleep wake pattern
- Inattention
- Unaware / disoriented
- Memory deficits
Examination delirium
- Collateral history
- Rate and onset of confusion
- Underlying causes?
- Understanding of premorbid state
- Hypersensitivity?
- Drug and alcohol history
- Disturbances - hallucinations etc.
MSE delrium
Appearance - hypo or hyper alert, aggressive or purposeless behaviour
Speech - incoherent or rambling
Mood - low, irritable or anxious. Often labile
Thought - confused, ideas or reference, delusions
Perception - Illusions, hallucinations, misinterpretations
Cognition - disoriented, impaired memory, reduced conc and attention
Insight - poor
Hypoactive delirium
- Lethargy, dec motor activity and sleepiness
- Most common but also most unrecognised
- Can be confused with depression
Hyperactive delirium
- Agitation, irritability and restlessness with aggression
- Hallucinations and delusions prominent
- May be confused with functional psychoses
Mixed Delirium
Both hypo and hyper and signs of both.
Treatment delirium
- Underlying causes - infections, electrolyte disturbances, offending drugs, laxatives for faecal impaction, analgesia
- Reassurance and re-orientation - reduce anxiety and disorientation
- Provide appropriate environment - quiet, well lit room. Consistency in care and staff, reassuring nursing staff, familiar person - family or friends.
- Managing disturbed or violent / distressed behaviour
- encourage oral intake and pay attention to constinence. Verbal and non verbal deescalation techniques.
Avoid benzos and use low dose haloperidol
Ix Delirium
- Routine
- ABG, CT head, Lumbar puncture - depending on symptoms
- Diagnostic questionnaires
- Abbreviated mental test AMT
- Confusion assessment method CAM
- MMSE
Ddx delirium
- Dementia
- Mood disorders
- Late onset schizophrenia
- Dissociative disorders
- Hypothyroidism and hyperthyroid
Complications delirium
- Death
- Increased length of stay in hospital
- Dementia
- Falls
- Pressure sores
- Functional impairment
- Distress for person / family / carers.
- Nosocomial infections
Biological treatment considerations for delirium
Antipsychotics and benzos are never first line for managing delirium and providing reassurance and re-orientation and appropriate environment are main means - NICE.
Low dose antipsychotics are only to be used as last resort incase of violent or severely distressed behaviour.
Delirium vs Dementia
Sleep wake
Attention
Arousal
Autonomic features
Duration
Delusions
Course
Consciousness
Hallucinations
Onset
Psychomotor activity
Delirium
Disrupted
Markedly reduced
Increased or decreased
Abnormal
Hours to weeks
Fleeting
Fluctuating
Impaired
Common
Acute or subacute
Abnormal
Dementia
Normal
Normal
Normal
normal
Months to years
complex
stable / slow
no impairment
less common
chronic
normal
AMT - abbreviated mental test
- Age
- Time to nearest hour
- Recall address at end
- What year
- Location
- Identify 2 people
- DOB
- WW1
9.Current monarch - Count backwards from 20 to 1
> =8 means impairment unlikely
CAM - confusion assessment method
1 and 2 + either 3 or 4
1. Acute onset and fluctuating course
2. Inattention
3. Disorganised thinking
4. Alteration in consciousness.
Dementia
Generalised decline of memory, intellect and personality without impairment of consciousness - leading to functional impairment
Cause of AZ
degeneration of cholinergic neurone in the nucleus basalis of meynert, leading to a deficiency of acetylcholine.
Microscopic and macroscopic findings of AZ
- Microscopic - neurofibrillary tangles and B amyloid plaque formation
- Macroscopic - cortical atrophy - common hippocampal. Widened sulk and enlarged ventricles.
Irreversible causes dementia
- Neurodegenerative
- Infections - HIV, encephalitis, syphillis, CJD
- Toxins - Alcohol, barbiturates, benzodiazepines
- Vascular - vascular dementia, multi-infarct dementia, CVD
- Traumatic head injury
Reversible causes dementia
- Neuro - normal pressure hydrocephalus, intracranial tumours, chronic subdural haematoma.
- Vitamin deficiencies - B12, folic acid, thiamine, nicotinic acid
- Endocrine - Cushing syndrome, hypothyroidism
DEMENTIA
- Drugs - barbiturates
- Eyes and ears - visual or hearing impairment
- Metabolic - bushings / hypothyroidism
- Emotional
- Nutritional deficiencies / normal pressure hydrocephalus
- Tumours / Trauma
- Infections
- Alcoholism / Athersclerosis
MSE Dementia
Appearance - unkempt
Speech - slow and confused, repetitive
Mood - low or normal
Thought - delusions
Perception - hallucinations in DLB.
Cognition - Affected in all dementia but varying degrees
Insight - Preserved initially but lost in latter stages.
Types of dementia
- Alzheimers
- Vascular - as a result of cerebrovascular disease
- Dementia with Lewy bodies
- Fronto temporal dementia -
- Other causes
- Dementia in Parkinsonism - Parkinsons first then dementia
DLB
Dementia then Parkinsons -
abnormal deposition of protein within the neuron’s of the brainstem, substantia nigra and neocortex.
Outside brainstem, LB are associated with more profound cholinergic loss than in AD.
Within brainstem more dopaminergic loss and parkinsonian like symptoms.
FTD
atrophy of frontal and temporal lobes of the brain. Picks disease - protein tangles (pick body) seen histologically.
Frontotemporal dementia
Cortical and Subcortical dementia
Cortical - AD and FTD
Subcortical dementias - DLB
Mixed - Vascular
Cortical vs subcortical dementia
Memory loss
Mood
Speech
Personality
Coordination
Praxis
Motor speed
Cortical
Severe
normal
early aphasia
indifferent
normal
apraxia
normal
Subcortical
Moderate
low
dysarthria
apathetic
impaired
normal
slow
ICD-10 for dementia
- Evidence of the following
- Decline in memory
- Decline in other cognitive abilities - deterioration in judgement and thinking such as planning or organising.
- Preserved awareness of the environment for a period of time long enough to demonstrate
- A decline in emotional control or motivation, or change in social behaviour manifested by one of the following:
- Emotional lability
- Irritability
- Apathy
- Coarsening of social behaviour
- For a confident diagnosis - must have been present for at least 6 months
10 step examination dementia
- Routine investigations
- Urine dipstick
- Chest Xray
- Sypholis serology and HIV testing
- Brain imaging
- ECG
- EEG
- Lumbar puncture
- Genetic tests
- Cognitive assessment
Ddx dementia
Normal ageing
Mild cognitive Impairment
Trauma
Depression
Late onset Schizophrenia
Amnesic syndrome
Learning Difficulty
Substance misuse
Drug side effects
Areas of impairment in dementia
My cat loves eating pigeons
Memory
Cognition
Language
Executive function
Personality
3 things that contribute to dementia
The three Ds
depression
drugs
delirium
Requirements for capacity
*understand the information that is relevant to the decision they want to
make
*retain the information long enough to be able to make the decision
*weigh up the information available to make the decision
*communicate their decision by any possible means, including talking, using
sign language, or through simple muscle movements such as blinking an
eye or squeezing a hand.
