Delirium and Dementia Flashcards

1
Q

What is a delirium?

A

Also known as Toxic Confusional State or Acute Organic Psychosis – Acute or Subacute Brain Failure; Impairment of Attention associated with Abnormalities of Perception and Mood
o DSM-IV Criteria – Disturbance of Consciousness (Reduced Environmental Awareness
and Reduced ability to Focus, Sustain or Shift Attention), Change in Cognition
(Memory, Orientation, Language, Perception); Disturbance should develop over a short period (hours/days) and Fluctuates over course of a day

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2
Q

Progression of Delirium

A

Confusion is usually worse at night with consequent Sleep Reversal; During the Acute phase, Thought and Speech are incoherent, Memory is impaired and Misconceptions can occur; Episodic Visual Hallucinations/Illusions and Persecutory Delusions occur

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3
Q

Differentials for Delirium

A

Developing, Deteriorating or Damaged brains are predisposed to Delirium; Differential should
include Delirium tremens (ETOH XS) and Lewy Body Dementia

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4
Q

Management of Delirium

A

• Collateral History and thorough examination of the patient could reveal cause
• Patient should be nurse and rehydrated in quiet single room etc
• Blood Tests – FBC, CRP, U/Es, LFTs, Thiamine, Vitamin B12 and Folate, Glucose, TFTs, Cortisol;
Imaging (CXR, CT/MRI Head if indicated), Consider Drug/Alcohol intoxication and review current Drug therapy
o Antipyretics should be given if febrile; Psychoactive drugs avoided

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5
Q

Management of Severe Delirium

A

Haloperidol is effective; Benzodiazepines should not be used as first-line
and may even prolong confusion

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6
Q

How long does delirium last?

A

Delirium usually clears within a week or two; Prognosis depends on successful treatment of causative disease as well as underlying state of brain
o 25% of Delirious Elderly have underlying Dementia; 15% due to survive underlying illness and 40% are in institutional care at 6 months

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7
Q

What is dementia?

A

• Clinical Syndrome with multiple causes; Defined
by Acquired loss of Higher Mental function affecting two or more cognitive domains (Episodic Memory, Language, Frontal Executive, Visuospatial Function, Apraxia or Agnosia)
• Of sufficient severity to significantly cause
Social/Occupational Impairment occurring in
Clear Consciousness (C/f Delirium)

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8
Q

Mild Cognitive Impairment

A

Intermediate state between Normal Cognition and Dementia; Might often be only Memory Impairment
(Amnestic MCI)
o Might be “Pre-dementia” state; 10-15% MCI patients develop Alzheimer’s Disease

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9
Q

Assessment of Dementia

A

• MMSE – Relatively insensitive to milder cognitive impairment and Frontal Lobe Dysfunction
o Addenbrooke’s Cognitive Examination (ACE) – Addresses deficiencies in MMSE
• Individual Cognitive Domains tested separately – Clock drawing (Parietal), Naming and Reading Tasks (Language), Verbal Fluency, Cognitive Estimation and Stop-go Tasks for Frontal
Lobe Function (Frontal Assessment Battery), Recall Recent News Events (Episodic Memory)
• Primitive Reflexes (Frontal Release Signs) e.g. Grasp, Palmo-mental and Pout reflexes, perseveration or Utilisation Behaviour
• Praxis – Copying Hand Gestures and Miming
• Complete Neurological Examination including
looking for evidence of Papilloedema, Parkinsonism, Myoclonus, Gait disturbance

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10
Q

Investigations in Dementia

A

• Blood Tests – FBC, Vitamin B12, TFT, U/Es, LFTs,
Glucose and ESR
• CT for excluding Structural lesions (E.g. Tumours, Hydrocephalus); MRI helps identify patterns of regional brain atrophy to distinguish between different types of
degenerative dementia
• Detailed Neuropsychometric Assessments for
quantification and tracking deterioration
• Younger patients <65yrs should have more
intensive investigations, including EEG, Genetic
Testing (Huntington’s, Familial Alzheimer’s Disease), HIV Serology, Metabolic tests etc

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11
Q

Management of Dementia

A
  • Management is supportive; Preserve Dignity and Provide care for as long as possible within the home environment
  • Multidisciplinary Team includes Dementia Clinical Nurse Specialists, Geriatricians, OT/PT
  • Participation in Cognitively Demanding activities in later life might delay onset; High dose B Vitamins might slow conversion of MCI to Alzheimer’s Disease
  • Cholinesterase Inhibitors (Donepezil, Rivastigmine, Galantamine) inhibit CNS
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12
Q

When should cholinesterase inhibitors be used or not?

A

Effective in Dementia with

Lewy Bodies and Parkinson’s Dementia but not in Frontotemporal or Vascular Dementia

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13
Q

Memantine

A

NMDA Receptor Antagonist; Used in Moderate/Severe AD where Cholinesterase Inhibitors not tolerated

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