Delirium and Memory Problems Flashcards
What is the most common mental health problem in hospitalised patients above the age of 65?
Delirium
What are the main features of delirium?
Impaired consciousness Disturbed cognition Psychomotor disturbance Emotional disturbance Disturbed sleep-wake cycle
What might be seen clinically if a patient has impaired consciousness?
Clouding
Drowsiness
Stupor
Coma
What might be seen clinically if a patient has disturbed cognition?
Disorientated for time and place
Impaired memory and attention
Impaired thinking
Perceptual disturbance (hallucinations, delusions)
What are the 2 main psychomotor variants of delirium?
Hypoactive
Hyperactive
Can get mixed picture
What might be seen clinically if a patient has hypoactive delirium?
Confusion
Sedation
Depression (misdiagnosis)
What might be seen clinically if a patient has hyperactive delirium?
Agitation
Aggression
Hallucinations, delusions
Disorientation
Describe the course of delirium
Fluctuating, transient course
Rapid onset
Can last days to months depending on cause
What drugs can typically cause delirium?
Anticholinergic Anticonvulsant Parkinson drugs Steroids Opiates Alcohol Illicit drugs
Withdrawal from what substances can typically cause delirium?
Alcohol
Benzodiazepines
Barbiturates
Illicit drugs
List some metabolic abnormalities that can typically cause delirium
Hypoxia
Hypoglycaemia
Hypo/hyperthyroidism
Hypopituitarism
No identifiable cause excludes a diagnosis of delirium. True/False?
False
List the main risk factors for delirium
Elderly Existing dementia Sensory deficits Perioperative Previous episode Immobility Social isolation, stress
Sedating drugs can worsen delirium. True/False?
True
How is delirium due to alcohol withdrawal managed with medication?
Benzodiazepine (chloridazepoxide, diazepam)
What is the general management of delirium?
1ST LINE = environmental measures (reality oreintation, sensory impairment, light, noise, basic needs)
Antipsychotic - haloperidol
Lorazepam in PD, LWB dementia, neuroepileptic sensitivity
Who typically gets hyperactive delirium?
Elderly with recent injury e.g. hip fracture
What time of day is delirium typically worse?
Night
What is the shortest type of memory?
Sensory memory (less than 1 sec) Short-term (less than 1 minute)
List the 2 main domains of long-term memory and their function
Explicit memory (conscious) Implicit memory (unconscious)
Procedural memory is part of what - implicit or explicit memory? What kind of memory does it enable?
Implicit memory
Remembering skills and doing tasks
Declarative memory is part of what - implicit or explicit memory? What kind of memory does it enable?
Explicit memory
Remembering facts and events
What are the 2 main domains of declarative memory and their memory functions?
Episodic memory (events, experiences) Semantic memory (facts, concepts)
What is anterograde amnesia?
Difficulty acquiring new material and remembering events since onset of illness/injury
What is retrograde amnesia?
Difficulty remembering information prior to onset of illness/injury
List some typical reports of memory problems
Forgetting a message Losing track of conversation Forgetting to do things Inability to navigate to familiar places Misplacing things Struggling with names
What are the main domains assessed in cognitive screening?
Memory Attention, concentration Executive function Visuo-spatial function Language
List diagnostic investigations used in delirium
Formal cognitive testing Urine analysis FBC, U+Es, LFTs Thyroid function Blood glucose CRP B12 + folate CXR/ CT brain EEG (diffuse background slow wave activity)
Which two illnesses have a strong association with development of depression?
Stroke
MI
List precipitating causes of delirium
PINCH ME
PAIN
ILLNESS: urinary retention
INFECTION: UTI, lungs, stomach
NEUROLOGICAL: withdrawal, alcohol
CONSTIPATION CATHETER CARDIOEMBOLIC HYDRATION HYPO: thyroid, natraemia, kalaemaia, thermia, glycaemia, xia
MEDICATION: new meds/ change in meds ENVIRONMENTAL: hospital, surgery
List the criteria for diagnosing dementia
2 or more of: Forgetfulness Memory loss Confusion Poor reasoning and logic Personality change Poor judgement Ability to focus Visual perception
Compare the memory impairment in dementia, delirium and depression
DEMENTIA: Recent and remote impairment
DELIRIUM: Recent impairment
DEPRESSION: Remote intact, concentration poor
List cognitive tests used to diagnose dementia
4AT (rapid screening for delirium) MMSE Bedside tests (GPCOG, 6CIT) MoCA (rapid screening for mild cognitive dysfunction) ACER (between MMSE and neurophysiology) Frontal assessment battery Neurophysiology
What is the cute off for diagnosis of dementia using the MMSE?
<24/30
Clock drawing tests the function of which lobes of the brain?
Fronto-parietal lobes
What is the purpose of neurophysiological assessment?
Whether intellectual/ behavioural decline is linked to disease of CNS
Define ‘dementia’
Syndrome due to disease of brain, which is irreversible and progressive, with global cognitive decline over months-years, and reduced emotional control, social ability and motivation
List non-pharmacological management options for dementia
Environmental measures (sleep, exercise, medications, carer education) Post diagnostic counselling Advance planning Practical and legal advice inc. driving OT assessment
What is ‘mild cognitive impairment’?
Minor problems with cognition - their mental abilities such as memory or thinking - that are worse than expected for a healthy person of their age.
Increased risk of developing dementia
Alzheimer’s disease typically follows what pattern of memory loss? Which lobe of the brain is affected first?
Short-term memory loss first
Medial temporal lobe
Vascular dementia follows what pattern of decline?
Step-wise decline in cognition
List the three main variants of fronto-temporal dementia
Behavioural variant
Primary progressive aphasia
Semantic dementia
List red flags for dementia presentation
Fast progression Young patient Neurological sings FHx of rare/ young dementia Clues in PMHx e.g. HIV
A SPECT scan is most useful for diagnosing which type of dementia?
Fronto-temporal dementia
A DaT scan is most useful for diagnosing which type of dementia? What is the classical appearance?
Lewy body or Parkinson’s dementia
Full stop sign
An MRI scan is most useful for diagnosing which type of dementia?
Younger patients, fast progression, atypical presentation
How does Alzheimer’s disease present on imaging?
Cortical atrophy
Dilated ventricles
Widened sulci
Narrowed gyrus
Where do small vessel changes typically occur in the brain in vascular dementia?
Periventricular white matter
What is the mechanism of action of anti-cholinesterase inhibitors?
Block cholinesterase and increase ACh in synapse
Which anti-cholinesterase inhibitors are first line in Alzheimer’s disease?
Donepezil
Rivastigmine
Galantamine
Which anti-cholinesterase inhibitors are first line in DLB and PD? What symptom do they help control?
Rivastigmine
Donepezil
Visual hallucinations
List side effects of anti-cholinesterase inhibitors
GI (nausea, diarrhoea)
Headache
Muscle cramps
Bradycardia
Anti-cholinesterase inhibitors are contraindicated in…
Active peptic ulcers
Severe asthma
Severe COPD
Which medication should be used in Alzheimer’s disease when anti-cholinesterase inhibitors are contraindicated? What do they help prevent?
Memantine
BPSD (Behavioral and psychological symptoms of dementia)
List side effects of memantine
Hypertension Sedation Dizziness Headache Constipation
What other class of drug can be considered for prescribing in dementia?
Antidepressants
Behavioural difficulties in fronto-temporal dementia can be controlled with which medication?
Trazadone
Antipsychotics are contraindicated in which type of dementia?
Lewy body dementia
List aetiology of dementia
GENETIC: Huntingdons’s, wilson’s, porphyria
INFECTIOUS: Syphillus, prions, encephalitis
CVD
METABOLIC: Hypothyroidism, thiamine (alcohol)
CEREBRAL TUMOURS
DEGENERATIVE: Alzheimer’s, parkinson’s
DEMYELINATION
TRAUMA: Major head injury
NORMAL PRESSURE HYDROCEPHALUS
