Delirium and Dementia Flashcards
What is the DSM5 definition of Delirium?
1) Altered consciousness/attention/awareness - hypervigilant - decreased attention, decreased GCS 2) cognitive impairment (acute onset of memory, language, perceptual) 3) fluctuation there is a physiologic cause not diagnostic but psychotic Sxs (delusions, hallucinations, illusions) others: - disorientation - behavioural disturbance Two Types: - hyperactive - hypoactive
Outline some causes of delirium
DELIRIUM D - Drugs E - Electrolytes L - Lack of drugs, food, water I - infection R - reduced sensory input I - intra-cranial causes U - urinary retention M - mobility and myocardium Medical Illness - infection - electrolytes - organ failure - stroke Medications - antichilinergic agents, benzos, TCAs - NSAIDs - opioids Surgical - anaethetics Uncontrolled Pain Environment
Outline some Predisposing factors
- advancing age - cognitive impairment - depression - sensory impairment -polypharmacy - comorbidities
What is the Confusion Assessment Method for delirium?
Need 1 and 2 with 3 or 4 1 - acute + fluctuating 2 - Inattention (necessary) - digit span - days of the week backwards 3 - disorganised thinking 4 - change in level of conciousness 4AT another assessment tool, assessing alertness - 4AMT - count backwards from 100, world backwards.
What is the management of delirium?
- identify and treat precipitating factors/predisposing factors - BSL, FBE (anaemia), UEC (Na/K+), TSH, CMP, CRP (infection), urine dipstick (UTI)
- supportive care: (MARKS)
- maintain fluids + nutrition
- avoid physical restraints
- environmental modification: - comfort, - involve family - frequent orientation
- decrease room and staff changes
- encourage mobility + self-care - avoid sleep depreivation
- Pharmacological Mg -
- if patient threatens safety Atypicals (olanzapine, risperidone, quetiapine)
- Antipsychotics (haloperidol)
- Benzos - only in alcohol withdrawal
- prevent complications e.g. falls
What are the 5 Ps of Agitation in the Elderly if they have BPSD or Delirium?
Pee Poo Pain Pus Pills
What is BPSD and what are the variations of it?
Behavioural and psychological symptoms of dementia
- agitation
- delusions
- shouting
- hallucinations
- aggression group based on symptoms:
- Psychotic - aggression
- Mood - anxiety
- Miscellaneous - disrobing, vocalising, sexual dysfunction
- SAMPIE acronym
- sexual disinhibition
- agitation
- mood disorder
- psychosis
- inappropriate vocalisation
- eating problems
- management? - non pharmacological, thorough observation and find triggers.
What is an important DDx for Delirium?
Lewy Body Dementia - can also give a fluctuating picture with inattention and consciousness alterations (usually not acute though)
What is the criteria for Dementia?
1) cognitive decline - memory, executive function, language, attention, visuospatial 2) timeframe (chronic and progressive irreversible) 3) impacting function 4) exclude delirium and depression 5) change from previous level of cognitive function (i.e. not congenital) mild cognitive impairment is not the same 1.5SD on neuropsych testing prodromal is MCI + amyloid/tau
Name some types of Dementia and the areas that are affected generally.
General Cortical
- AD + FTD - A’s:
- amnesia
- aphasia
- apraxia (purposeful actions)
- acalculia (no simple calculations)
- Subcortical -
- Vascular + PD/LB physical signs -
- dysphagia -
- dysarthria -
- early incontinence slow thinking + speaking memory -
- retrieval can remember with prompts
- Examples:
- AD
- predominately memory (amnesic, visuospatial, language - expressive) -
- BPSD -
- Executive function early on
- Vascular dementia -
- stepwise decline -
- subcortical features - dysphagia or other signs
- falls, speech, problems with planning - focal neurological signs
- LBD -
- fluctuating attention -
- visual hallucinations -
- parkinsonism -
- vivid dreams, REM, anosmia -
- memory usually preserved
- FTD -
- peaks in mid 50s -
- often + FHx - (Picks disease)
- 2 types - behavioural early vs language (semantic vs non-fluent aphasia
- 3 behavioural types and a language variant, marked personality changes.
- tendency to hoard things.
- AD
What are some treatments for dementia?
- Allied health
- community health services
- ACAS
- CADMS +/- neuropsych
- assess capacity
- contact family
- EPOA
- VicRoads
- AD - cholinesterase inhibitors (e.g. donepezil)
- helps more with BPSD -
- 30-60% effective -
- needs PBS SE -
- N/V/D, vivid dreams
- Memantine - NMDA system but extremely restrictive
- LBD - cholinesterase inhibitors but not in the PBS -
- sensitive to risperidone -
- L-DOPA for physical (may cause progression and confusion)
- FTD -
- supportive/behavioural
- Medication - benzos (sleep disturbance) -
- neuroleptics -
- amantidine (with distractibility) -
- valproate (impulsivity)
- supportive/behavioural
What are some differences on brain scan?
AD - CT - global atrophy - MRI - hipocampal + mesiotemporal loss VD - MRI - show evidence of cerebrovascular disease LBD - usually normal FTD - frontal and temporal atrophy - EEG normal - genetic testing CJD - subcortical FLAIR - CSF analysis EEG - periodic complex
What is the prevention of delirium?
- treat pain - maintaining orientation (clocks/calenders) - minimise noise - hydration and nutrition - stop infections (IV line, catheters)
What is the cognitive assessment for dementia?
- MMSE <24/30 - cultural bias
- RUDAS <24/30 but less well validated
Questions to ask for Dementia Patient?
Questions to ask: (SAM FAPS)
- is the patient driving (no longer allowed to drive)
- medication compliance
- safety at home
- financial abilities
- EPOA
- ADLs
ADLs: cognitive domains, bills frontal, driving (lost) - visuospatial
pADLS
dADLs
cADLs