DELIRIUM & DEMENTIA Flashcards

Question

Non-pharmacological interventions for mild-moderate dementia?

Answer 1

Cognitive stimulation therapy Group reminiscence therapy Cognitive rehabilitation or OT to support functional ability

Answer 2

this uses objects from daily life to stimulate memory and enable people to value their experiences

Answer 3

Acetylcholinesterase inhibtiors e.g. donepezil, galantamine, rivastigmine Memantine (NMDA receptor antagonist) antipsychotics should only be used for patients at risk of harming themselves or others, or when the agitation, hallucinations or delusions are causing them severe distress

Answer 4

Vascular dementia

Answer 5

17% of dementia cases Overall stroke doubles the risk of developing dementia Incidence increases with age

Answer 6

Stroke-related VD – multi-infarct or single-infarct dementia Subcortical VD – caused by small vessel disease Mixed dementia – the presence of both VD and Alzheimer’s disease

Answer 7

History of stroke or TIA AF Hypertension DM Hyperlipidaemia Smoking Obesity CHD FH of stroke or CVD

Answer 8

CADASIL - Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy

Answer 9

Several months/years of a history of a sudden or stepwise deterioriation of cognitive function Focal neurological abnormalities e.g. hemiparesis or visual field defects Difficulty with attention and concentration Seizures Memory disturbance Gait disturbance Speech disturbance Emotional disturbance

Answer 10

NINDS-AIREN criteria

Answer 11

Presence of cognitive decline that interferes with ADLs, not due to secondary effects of the cerebrovascular event Cerebrovascular disease defined by neurological signs or brain imaging Temporal relationship between the 2 above disorders: the onset of dementia within 3 months following a recognised stroke OR an abrupt deterioration in cognitive functions OR fluctuating stepwise progression of cognitive deficits

Answer 12

Detec and address CVD risk factors Non-pharm - cognitive stimulation programmes, multisensory stimulation, music and art therapy, animal-assisted therapy Mange challenging behaviours Pharm - only consider AChE inhibitors if hey have concurrent alzheimers, parkinsons or LBD

Answer 13

MRI or CT head SPECT scans - glucose scan for alzheimers or other type for LBD Cerebrospinal fluid exam may be useful in excluding infection/malignancy and making a positive diagnosis of alzheimers or diagnosing prion disease

Answer 14

Accumulation of alpha synuclein cytoplasmic inclusions in the substantia nigra, paralimbic and neocortical areas

Answer 15

Parkinson’s disease - motor symptoms typically present at least 1 year before cognitive symptoms Lewy body dementia - the cognitive symptoms present within 1 year of the motor symptoms and typically occurs first

Answer 16

Progressive cognitive impairment - typically before parkinsonism but definitely within 1 year of it Fluctuating cognition Early impairments in attention and executive functions too Parkinsonisms e.g. bradykinesia, resting tremor or rigidity Recurrent visual hallucinations REM sleep behaviour disorders

Answer 17

SPECT scan - aka a DaTscan which shows dopamine activity around the striatum

Answer 18

Donepezil or rivastigmine are first line

Answer 19

Neuroleptics (aka antipsychotic meds) As these pt are extremely sensitive to them and may develop irreversible parkinsonism

Answer 20

Frontotemporal lobar degeneration

Answer 21

Frontotemporal dementia (picks disease) Progressive non fluent aphasia Semantic dementia

Answer 22

Before the age of 65

Answer 23

Picks disease (frontotemporal dementia)

Answer 24

Insidious onset Most common: Personality change Impaired social conduct Hyperorality Apathy Social or sexual disinhibition Increased appetite Perseveration behaviours Note: other cognitive functions e.g. memory and perception may be relatively preserved

Answer 25

Atrophy of frontal and temporal lobes Focal gyral atrophy with a knife-blade appearance

Answer 26

Behavioural variant frontotemporal dementia Primary progressive aphasia

Answer 27

Changes in personality and behaviour e.g: Losing motivation Struggling to focus on tasks Difficulty in planning, organising and making decisions Losing inhibitions Losing the ability to understand what others are thinking or feeling Repetitive or obsessive behaviours Craving sweet, fatty foods or carbs

Answer 28

Semantic dementia and progressive nonfluent aphasia

Answer 29

Progressive decline in the understanding of word meanings Speech may still be fluent, but there is difficulty in name-retrieval and use of less precise terms Are unable to determine the meanings of common words when asked This tends to develop into the inability to recognise objects, or familiar faces (prosopagnosia)

Answer 30

Progressive breakdown in the output of language The speech takes effort and is not fluent Speech apraxia (poor articulation) or disorders of speech sound There also tends to be impaired comprehension of sentences and an impact on literacy skills

Answer 31

Behavioural interventions Pharmacotherapy e.g. SSRIs and antipsychotics for behavioural symptoms but there is no evidence for any drugs to treat the dementia symptoms

Answer 32

Remove the threat Create space Be on their side Get at or below eye level Use hand under hand Breathe in sync Calm voice Relax body Attend to needs Be willing to go where they are

Answer 33

A rapidly progressive neurological condition caused by prion proteins that induce the formation of amyloid folds resulting in tightly packed beta-pleated sheets resistant to proteases Causes rapid onset dementia and myoclonus

Answer 34

Sporadic CJD - 85% of cases, mean age of onset is 65 Variant CJD = mean age of onset is 25 and median survival is 13 months, likely caused by consuming meat from a cow that had bovine spongiform encephalopathy Familial = very rare

Answer 35

Short history and rapid onset Biological symptoms e.g. weight loss, sleep disturbance Pt worried about their poor memory Reluctant to take tests and get disappointed with results Will likely say ‘I dont know’ when trying to remember things but then will likely remember when prompted Global memory loss rather than just recent like in dementia Variable mini mental test score

Answer 36

acute onset impairment of consciousness fluctuation of symptoms: worse at night, periods of normality abnormal perception (e.g. illusions and hallucinations) agitation, fear delusions

Answer 37

An acute, fluctuating syndrome of encephalopathy causing disturbed consciousness, attention, cognition and perception

Answer 38

Hyperactive delirium Hypoactive delirium Mixed delirium

Answer 39

Being >65 Cohmitive impairment e.g. dementia Frailty or multiple comorbidities Significant injuries e.g. hip fracture Functional impairment e.g. immobility Iatrogenic events e.g. catheters, surgery, poly pharmacy Alcohol excess Sensory impairment Poor nutrition Lack of stimulation Terminal phase of disease

Answer 40

Infections Metabolic disturbances e.g. hypoglycaemia or dehydration CV disrders Respiratory disorders Neurological disorders Endocrine disorders e.g. thyroid dysfunction Urological disorders e.g. retention GI disorders e.g. constipation Severe uncontrolled pain Alcohol intoxication or withdrawal Medications psychocial factors e.g. sleep deprivation, emotional stress, change in environment

Answer 41

Opioids Benzos Dihydropyridines Antihistamines Others: Anti parkinsons meds TCAs Lithiums Antipsychotics Anticonvulsants Antiarrhythmics Antihypertensives H2 receptor antagonists Steroids NSAIDs

Answer 42

General population prevalence 0.4% In hospital older people up to 50% Complicates up to 60% of major surgical procedures Occurs in up to 85% of ITU admissions Up to 88% in end of life care units in the weeks leading up to death

Answer 43

Increased mortality: Patients who present to an emergency department with delirium have a 70% increased risk of death in the first 6 months after the visit Increased length of stay in hospital Nosocomial infections Increased risk of admission to long term care or re-admission to hospital More likely to develop dementia Falls Pressure sores Continence problems Malnutrition Functional impairment Distress for the person, their family or carers

Answer 44

Pre-existing dementia or cognitive impairment Older age and frailty Hypoxic illness Visual impairment Hypoactive delirium Longer duration and increased severity of delirium

Answer 45

Behaviour change over hours to days. Symptoms usually fluctuate with lucks intervals during the day and worst disturbances at night. May include altered cognitive function, inattention, disorganised thinking, altered perception, altered physical function e.g. hyperactive or hypoactive Altered social behaviour e.g. labile mood and emotions Altered level of consciousness or impaired/reversed sleep wake cycle Falls Loss of appetite

Answer 46

the person may have increased sensitivity to their immediate surroundings with agitation, restlessness, sleep disturbance, and hypervigilance. Restlessness and wandering are common.

Answer 47

the person may be lethargic, have reduced mobility and movement, lack interest in daily activities, have a reduced appetite, and become quiet and withdrawn.

Answer 48

Carrying out a cognitive assessment e.g. DSM-5 criteria or the short-confusion assessment method or 4A;s test

Answer 49

Confusion that has developed suddenly and fluctuates, AND… Inattention — ask if the person is easily distracted or has difficulty in focusing attention, AND EITHER… Disorganised thinking — ask if the person's thinking is disorganised, incoherent, illogical, or unpredictable (for example they have an unclear flow of ideas, change subject unpredictably, or have rambling or irrelevant conversation), OR… Altered level of consciousness — ask about changes in level of consciousness from alertness to: lethargy (drowsy, easily aroused); stupor (difficult to arouse); comatose (unable to be aroused); or hypervigilant (hyper-alert).

Answer 50

A. Disturbance in attention (reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment). B. The disturbance develops over a short period of time (usually hours to a few days), represents an acute change from baseline attention and awareness, and tends to fluctuate in severity during a day. C. An additional disturbance in cognition (such as memory deficit, disorientation, language, visuospatial ability, or perception). D. The disturbances in Criteria A and C are not better explained by a pre-existing, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal such as coma. E. There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication, or withdrawal (due to a drug of abuse or to a medication), or exposure to a toxin, or is due to multiple aetiologies.

Answer 51

This is a short, four-item tool designed for use in clinical practice to confirm a diagnosis of delirium The four items are alertness, cognition (a short test of orientation), attention (recitation of the months in backwards order), and the presence of acute change or fluctuating course.

Answer 52

Urinalysis Sputum culture FBC Folate and B12 U&Es HbA1c Calcium LFTs CRP and ESR Drug levels TFTs CXR ECG

Answer 53

Admit to hopsital for close monitoring Correct any precipitating factors Dont move them! Optimise treatment of comorbidities Include family and carers Try reorientation strategies Maintain safe mobility Normalise the sleep-wake cycle Manage any challenging behaviour with deescalation techniques Explain the diagnosis Follow up within 24 hours Low dose haloperidol may be used short term

Answer 54

the cumulative effect on an individual of taking one or more medications with anticholinergic activity. Increases risk of cognitive impairment, falls and all-cause mortality in older people

Answer 55

Alertness: are they drowsy, agitated, hyperactive Age, date of birth, place, current year Attention: tell me the months of the year backwards Acute change or fluctuating course: evidence of significant change in alertness/cognition/mental function arising over the last 2 weeks and still evident in the last 24 hours?

Answer 56

dementia (rapid onset) myoclonus psychological symptoms such as anxiety, withdrawal and dysphonia are the most common presenting features in new variant CJD

Answer 57

ACE-III or MOCA