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ELDERLY > DELIRIUM & DEMENTIA > Flashcards

DELIRIUM & DEMENTIA Flashcards

1
Q

What is dementia?

A

A progressive, irreversible clinical syndrome with a range of cognitive and behavioural sympotms including memory loss, problems with reasoning and communication, change in personality and a reduction in the person’s ability to carry out ADLs

For a diagnosis to be made the person must have an impairment in at least 2 of the following cognitive domains: memory, language, behaviour, visuospatial or executive function. It must cause significant functional decline in usually activities or work and must not be able to be explained by delirium or other major psychiatric disorders

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2
Q

What is early onset dementia?

A

Dementia that develop s enforce the age of 65

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3
Q

What is mild cognitive impairment

A

cognitive impairment that does not fulfil the diagnostic criteria for dementia, for example, because only one cognitive domain is affected, or deficits do not significantly affect daily activities.

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4
Q

Causes of dementia?

A

Alzheimers
Vascular dementia
Dementia with Lewy bodies
Frontotemporal dementia
Parkinson’s disease dementia
Progressive supranuclear palsy
Huntingtons disease
Prion disease e.g. Creutzfeldt-Jakob disease
Normal pressure hydrocephalus
Chronic subdural haematoma
Benign tumours
Metabolic and endocrine disorders e.g. chronic hypothyroidism
Vitamin deficiencies e.g. B12 and thiamine
Infections e.g. HIV, syphilis, CNS infections
Inflammatory and autoimmune disorders
Transient epileptic amnesia
Alcohol
MS
Corticobasal degeneration

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5
Q

Non-modifiable risk factors for dementia?

A

Age - strongest risk factor
Mild cognitive impairment - 1/3rd will develop dementia within 3 years
Learning disability
Genetics - APP, presenilin genes, alzheimers, ApoE
Cardiovascular disease
Cerebrovascular disease
Parkinson’s disease

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6
Q

Modifiable risk factors for dementia?

A

Lower educational attainment
Hypertension
Hearing impairment
Smoking
Obesity
Depression
No physical activity
Low social engagement and support
High alcohol consumption
Traumatic brain injury
Air pollution

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7
Q

Protective factors for dementia?

A

High levels of education, mentally demanding jobs, cognitive stimulation
Physical activity
Being socially active
Moderate alcohol consumption
Eat a healthy, balanced diet

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8
Q

Epidemiology of dementia?

A

In 2019 there were almost 885000 older people living with dementia in the UK
By 2040 this is expected to be 1.6 million
Prevalence rate of dementia among those over 65 in the UK is 7.1%
1 in 20 with dementia are under 65

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9
Q

Prognosis of dementia?

A

Life-long condition and no curative Tx
Dementia and Alzheimer’s are the leading cause of death for women and second leading cause for men
For those diagnosed in 60/70s median lifespan is 7-10 years, but this is reduced to 3 years for people diagnosed in their 90s
Dementia has been found to progress more rapidly following an episode of delirium

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10
Q

Complications of dementia?

A

Disability, dependency and morbidity - unable to carry out ADLs, complex care needs, mobility issues which can lead to falls, social isolation
Behavioural and psychological sympotms of dementia
Institutionalisation
Carer morbidity
Financial hardship

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11
Q

History taking for ?dementia

A

Timescale of onset of Sx and deterioration
Impact the symptoms have on ADLs
Cognitive, behavioural and psychological symptoms of dementia
Comorbidities e.g. strokes, parkinsons, depression, epilepsy
RF for dementia
Medication history
FHx of dementia
Alcohol or drug use

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12
Q

Physical examination for ?dementia

A

Focal neurological signs.
- Coordination and gait abnormalities.
- Sensory findings — such as peripheral neuropathy.
- Motor symptoms — hemiparesis, tremor, rigidity, bradykinesia.

Visual or auditory problems.

Cardiovascular signs, such as hypertension, arrhythmias, or peripheral vascular disease.

Other possible causes of symptoms, such as physical or mental illness (for example, head trauma or delirium).

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13
Q

Investigtaions to order to exclude reversible causes of cognitive decline?

A

FBC
ESR/CRP
U&Es
Ca2+
HbA1c
LFTs
TFTs
Serum B12 and folate
Urine dip
Neuroimaging e.g. CT head

(Others if clinically indicated by include syphilis serology and HIV testing)

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14
Q

Cognitive assessment tools for dementia?

A

10 point cognitive screener
6 item cognitive impairment test
MOCA test
ACE III test
4AT

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15
Q

Differential diagnoses for dementia?

A

Normal age-related memory changes
Mild cognitive impairment
Depression
Delirium
Vitamin deficiency
Hypothyroidism
Adverse drug effects
Normal pressure hydrocephalus
Sensory deficiets e.g. hearing impairment

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16
Q

What is the most common form of dementia in the UK?

A

Alzheimers

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17
Q

Genes for alzheimers?

A

5% are inherited in autosomal dominant trait - mutations in amyloid precursor protein, presenilin 1 and presenilin 2 genes
Apoportein E allele E4 gene

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18
Q

Why do people with Down’s syndrome have an increased risk of developing alzheimers disease?

A

In Down’s syndrome they have an extra copy of chromosome 21 which contains the gene that codes for Amyloid precursor protein
This is why they often get Alzheimer’s at a younger age too as this gene is linked to younger onset

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19
Q

Pathophysiology of alzheimers disease?

A

Type A-Beta-amyloid proteins are deposited forming cortical plaques
Abnormal aggregations of and hyperphosphorylation of the tau protein cause intraneuronal neurofibrillary tangles

These lead to damage to the ascending forebrain projection = deficit of acetylcholine

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20
Q

Macroscopic pathological changes in Alzheimer’s?

A

Widespread cerebral atrophy, particularly affecting the medial temporal lobes (especially the cortex and hippocampus)

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21
Q

Clinical features of alzheimers disease?

A

Usually insidious onset
The presenting symptom is usually loss of recent memory first (as hippocampus is affected first), and often difficulty with executive function and/or nominal dysphasia.
There is also loss of episodic memory — this may include memory loss for recent events, repeated questioning, and difficulty learning new information.
Cognitive deficits may include aphasia, apraxia, and agnosia.

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22
Q

5 As for alzheimers?

A

Amnesia
Agnosia
Apraxia
Aphasia
Associated behaviours

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23
Q

What is sundowning?

A

When a person with dementia becomes severely agitated or confused towards the late afternoon or early evening

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24
Q

Behavioural and psychological symptoms of dementia?

A

Psychosis
Agitation
Emotional lability
Depression and anxiety
Withdrawal or apathy
Disinhibition
Motor disturbance - wandering, restlessness, pacing
Sleep cycle disturbances
Tendency to repeat phrases or questions

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25
Q

Non-pharmacological interventions for mild-moderate dementia?

A

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

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26
Q

What is group reminiscence therapy?

A

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

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27
Q

Medical management of Alzheimer’s?

A

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

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28
Q

What is the second most common form of dementia after alzheimers?

A

Vascular dementia

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29
Q

Epidemiology of vascular dementia?

A

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

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30
Q

Main subtypes of vascular dementia?

A

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

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31
Q

Risk factors for vascular dementia?

A

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

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32
Q

What is the rare inherited type of vascular disease that can cause dementia?

A

CADASIL - Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy

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33
Q

Presentation of vascular dementia?

A

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

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34
Q

Criteria for diagnosing vascular dementia?

A

NINDS-AIREN criteria

35
Q

What is NINDS-AIREN criteria?

A

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

36
Q

Management of vascular dementia?

A

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

37
Q

Specialist investigations for suspected dementia?

A

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

38
Q

Pathophysiology of Lewy body dementia?

A

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

39
Q

Parkinson disease dementia vs Lewy body dementia?

A

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

40
Q

Presentation of Lewy body dementia?

A

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

41
Q

What scan can be done for Lewy body dementia diagnosis?

A

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

42
Q

Management of Lewy body dementia?

A

Donepezil or rivastigmine are first line

43
Q

What drugs must be avoided in Lewy body dementia and why?

A

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

44
Q

What is the third most common type of dementia after alzheimers and Lewy body dementia?

A

Frontotemporal lobar degeneration

45
Q

What are the 3 recognised types of frontotemporal lobar degeneration?

A

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

46
Q

What age does frontotemporal lobar dementia usually begin?

A

Before the age of 65

47
Q

Most common type of frontotemporal lobar degeneration?

A

Picks disease (frontotemporal dementia)

48
Q

Presentation of picks disease?

A

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

49
Q

Macroscopic changes seen in picks disease?

A

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

50
Q

What are the 2 subtypes of frontotemporal dementia?

A

Behavioural variant frontotemporal dementia
Primary progressive aphasia

51
Q

How does behavioural variant frontotemporal dementia present?

A

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

52
Q

What are the 2 forms of primary progressive aphasia?

A

Semantic dementia and progressive nonfluent aphasia

53
Q

How does semantic dementia present?

A

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)

54
Q

How does progressive nonfluent aphasia present?

A

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

55
Q

Management of frontotemporal dementia?

A

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

56
Q

Ways to de-escalate acute distress?

A

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

57
Q

What is creutzfeldt-Jakob disease?

A

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

58
Q

What are the types of Creutzfeldt-Jakob disease?

A

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

59
Q

Factors that suggest a diagnosis of depression rather than dementia?

A

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

60
Q

Factors that favour delirium over dementia?

A

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

61
Q

What is delirium?

A

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

62
Q

What are the types of delirium?

A

Hyperactive delirium
Hypoactive delirium
Mixed delirium

63
Q

Predisposing factors for delirium?

A

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

64
Q

What factors can precipitate delirium?

A

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

65
Q

Which medications are known to precipitate delirium?

A

Opioids
Benzos
Dihydropyridines
Antihistamines

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

66
Q

Epidemiology of delirium?

A

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

67
Q

Complications of delirium?

A

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

68
Q

Factors associated with a poorer prognosis for delirium?

A

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

69
Q

Presentation of delirium?

A

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

70
Q

How does hyperactive delirium present?

A

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

71
Q

How does hypoactive delirium present?

A

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

72
Q

How can you confirm a diagnosis of delirium?

A

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

73
Q

What are the criteria for the short-Confusion Assessment Method?

A

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).

74
Q

What is thr DSM-5 criteria for delirium?

A

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.

75
Q

What is the 4A’s test?

A

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.

76
Q

Investigations for delirium?

A

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

77
Q

Management of delirium?

A

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

78
Q

What is the anticholinergic burden?

A

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

79
Q

What is the 4AT tool?

A

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?

80
Q

Presentation of creutzfeldt Jacob disease?

A

dementia (rapid onset)
myoclonus

psychological symptoms such as anxiety, withdrawal and dysphonia are the most common presenting features in new variant CJD

81
Q

What is the best tool to use in hospital as a screening test for dementia?

A

AMTS

82
Q

What are the best tests to use to do a thorough assessment for dementia?

A

ACE-III or MOCA

83
Q

What screening tool is used for dementia?

A

4AT

84
Q

What has replaced the MMSE?

A

MoCA

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