delirium and dementia Flashcards
what is the definition of delirium?
acute onset of confusion that is fluctuating, reversible and affects all cognitive domains such as (attention, memory, executive function, visuospatial, language)
what are the diagnostic criterions of delirium?
disturbance of consciouscness w/ reduced ability to focus, sustain, shift attention
not explained by dementia (developing, established, evolving)
acute onset and fluctuating over the course of the day
disturbance is caused by medical condition through history, examination, investigations
what are some causes of delirium?
medication: anticholinergic drugs, antiparkinsonian medications, opioids, anxiolytics/hypnotics, other psychotropics, steroids, drug toxicities (lithium, digoxin, anticonvulsants)
infection: UTI, cellulitis, chest infection
cvs: MI, CHF
cerebrovascular: stroke, TIA, head injury, subdural haematoma
alcohol and intoxication:
medical/electrolyte disturbances: hypo/hypernatremia, renal failure, hyper/hypoglycemia, hypercalcemia
what are the risk factors for delirium?
> 70 years old
existing foreign body: catheter, IV line
use of physical restraint
pre-existing cognitive impairment - including dementia
visual impairment
depression
polypharmacy - addition of 3 or more medications
what are the sub classifications of delirium?
hypoactive; quiet, withdrawal, depressed, lethargic, drowsy, appear sedated, responds slowly to questions, withdrawn and sluggish state
hyperactive: agitated, hyper-alert, restless, often show hallucinations and delusions
mixed picture
name some environmental strategies for the treatment of delirium?
ensure lighting is appropriate for the time of the day
ensure the use of clock and calendar
avoid room changes
quiet environment
encourage family and friends to be involved in the patient’s care
encourage carers to bring in patient’s personal and familiar objects
name some clinical practice strategies for the treatment of delirium
ensure early mobilization adequate hydration and food intake hearing and visual aids regulation of bowel habits to avoid constipation promote regular and sufficient sleep manage discomfort and pain avoid use of physical constraint avoid use of psychoactive drugs if possible
what are the pharamcotherapy for delirium?
(first line) low dose antipsychotics:
haloeperidol/risperidone IM/IO (non sedating)
chlorpromazine (sedating, neuroleptic, anti-emetic properties)
atypical second gen neuroleptics such as risperidone, olanzapine, quetiapine
(second line) benzodiazepines
what is pharmacotherapy of choice for delirium d/t alcohol withdrawal (delirum tremens)
benzodiazpines (oxazepam, diazepam)
diazepam 20mg 2 hourly until symptoms subside. a cumulative dose of 60mg daily is usually adequate.
what are the pharamcotherapy for delirium?
(first line) low dose antipsychotics
haloeperidol/risperidone IM/IO (non sedating)
chlorpromazine (sedating, neuroleptic, anti-emetic properties)
atypical second gen neuroleptics such as risperidone, olanzapine, quetiapine
(second line) benzodiazepines
what is pharmacotherapy of choice for delirium d/t alcohol withdrawal (delirum tremens)
benzodiazpines (oxazepam, diazepam)
what pharmacotherapy should Alzheimer’s dementia receive?
anti-cholinesterase
donezepil
galantamine
rivastigmine (transdermal or oral)
what is the management guideline of Alzheimer’s dementia
confirm diagnosis
give anti-cholinesterase
treat existing comorbidities (such as medical/psychiatric)
avoid medications that can worsen confusion suhc as anti-cholinergics
carer support and education
organize practical and social support
refer for driving assessment
what are the features of vascular dementia
cognitive, motor, sensory dysfunction that worsens after every attack. neurological deficit + mutiple vascular risk factors
what are the features of dementia w/ lewy bodies
hallucination that is bizzare, parkinsonism and extra pyramidal signs
what are the features of pick’s disease
frontotemporal distribution hence personality and behavioural changes first w/ relative preservation of other cognitive functions
what are the features of huntington’s disease
more motor abnormalities such as psychomotor slowing, difficulty with complex tasks, classic choreotaform movements. Language/memory/insight remains relatively intact in the early and middle stages of the illness.
what are the classical neuropathology signs of Alzheimer’s disease?
diffused atrophy w/ flattened cortical sulci and enlarged cerebral ventricles
neurofibrillary tangles
presence of amyloid plaques
what is the distribution of neuropathlogy in Alzheimer’s disease?
parieto-temporal distribution
what are some of the risk factors of dementia?
age
positive family history
down’s syndrome
what is the most common first signs and symptoms of impairment in Alzheimer’s dementia?
memory impairment (short term memory impairment), denial of memory loss and depression
later stages - change in personality and affect, loss of language, spatial deficits, reasoning deficits, agitation and sleep disorders, sun-downing (more confusion as sun goes down) dysphagia, delusions or hallucinations
what is the most common first signs and symptoms of impairment in Alzheimer’s dementia?
memory impairment (short term memory impairment), denial of memory loss and depression
later stages - change in personality and affect, loss of language, spatial deficits, reasoning deficits, agitation and sleep disorders, dysphagia, delusions or hallucinations
what is the most common first signs and symptoms of impairment in Alzheimer’s dementia?
memory impairment
what are two substances most likely to cause hallucinations when patient is intoxicated?
cocaine, amphetamines
fast onset profound dementia, myoconic jerks, rigidity and ataxia. and EEG that shows periodic bursts of electrical activities superimposed on a slow background
creutzfeldt-jakob disease
progressive deterioration of cognition, easily irritatable, prone to aggressive outbursts, presents w/ irregular, purposely, asymmetrical movements of her limbs, face, and trunk
Huntington’s disease
what dementia do all trisomy 21 patinets get/
alzheimers dementia
what dementia is assoc w/ a long history of hypertension, focal neurological defects, and step-wise decline
vascular dementia OR mult-infarct dementia
ataxia, opthalmoplegia, confusion
wernicke’s encelopahy treated w/ b1 (thiamine)
dementia, ataxia, urinary incontinence
normal pressure hydrocephalus
dementia, ataxia, urinary incontinence
normal pressure hydrocephalus also shows fronto-subcortical dysfunction features - such as impaired attention, visuospatial deficits, poor judgement
young man, cognitive impairment, motor deficits, behavioural changes, impaired attention and concentratio, psychomotor slowing, forgetfulness, slow reaction time
HIV dementia
dementia + sensory ataxia + polyneuropathy + uupper motor neuron defect (barbinski’s sign)
b12 deficiency
dementia + cerebellar ataxia + opthalmoplegia
wernicke’s encephalopathy (B1 - thiamine deficiency)
dementia + high cholesterol
hypothyroidism
dementia + myoclonus
Creutzfedlt Jakob Disease
dementia + gait disturbances + urinary incontinence
normal pressure hydrocephalus
dementia w/ stepwise progression + pseudobulbar palsy (PBP)
Binswanger’s disease
dementia + chorea
Huntington’s disease
dementia + parkinsonism + syncopal attack
Shy-drager syndrome
dementia that is fluctuating + Parkinsonism
Lewy body dementia
dementia w/ sparing visuospatial skills + personality changes
frontemporal dementia
dementia + diarrhoea + dermatitis
Pellagra (B3 - niacin deficiency)
dementia + visual hallucinations + REM sleep disorders
Lewy body dementia
dementia that is fluctuating (confused w/ delirium( + Parkinsonism
Lewy body dementia
what can lewy dementia be confused with/
parkinson’s dementia, delirium
how do you differentiate between vascular and alzheimer’s dementia?
vascular dementia: often has pathology related to the CVA lobes involved c.f alzheimer’s disease
possible to have mixed alzheimer’s and vascular dementia
what are some symptoms of vascular dementia
(more common but not unique):
confusion, agitation, memory problems, unstable gait, urinary incontinence, wandering, poor attention
what are the symptoms of fronto-temporal dementia
Language: expressive and/or receptive aphasia
behavioural: disinhibition, impulsive, inappropriate social behaviour
what are the treatment for the following dementia:
- alzheimer’s
- vascular
- fronto-temporal
- dementia w/ Lewy body
- anti-cholinesterase
- prevent further CVA, supportive care for symptoms, family support
3, mood stabilizers (valproate), supportive care, safety, family support - anti-cholinesterase is effective, works well for visual hallucination (avoid anti-psychotics). supportive care and safety
what are the treatment for the following dementia:
- alzheimer’s
- vascular
- fronto-temporal
- dementia w/ Lewy body
- anti-cholinesterase
- prevent further CVA, supportive care for symptoms, family support
3, mood stabilizers (valproate), supportive care, safety, family support - anti-cholinesterase is effective, works well for visual hallucination (avoid anti-psychotics). supportive care and safety
dementia w/ stepwise progression + pseudobulbar palsy (PBP)
Binswanger’s disease (vascular dementia)
dementia + parkinsonism + syncopal attack
Shy-drager syndrome (multiple system atrophy)
what is the definition of dementia?
chronic or persistent neurocognitive decline with changes in: learning and memory language executive function complex attention perceptual motor function social cognition
what are some causes of reversible dementia?
b12 deficiency
wernickes
normal pressure hydrocephalus
hypothyroidism
dementia + broad based gait + visual disturbances
Wernickes
dementia + broad based shuffling gait + urinary incontinence
normal pressure hydrocephalus
dementia + cold intolerance + weight gain
hypothyroidism
ascending parasthesia + tongue soreness + weight loss
B12 deficiency
what are laboratory results of dementia?
calcium level complete blood count complete metabolic panel folate level thyroid stimulating hormone B12 deficiency specific risk factors: CSF, HIV, Lyme titre, RPR test
