Delirium & dementia

Question 1

Diagnosis of delirium ?

Answer 1

Impaired consciousness +

Perceptual disturbance (visual illusions / hallucinations) OR Cognitive disturbance (decreased concentration, memory, orientation, thinking/speech slow or incoherent)

+ Developed over short period of time and fluctuates
+evidence it may be due to a physical cause

Question 2

Features of delirium?

Answer 2

Can be hypo/hyperactive (eg restless / agitated)
DELUSIONS are common
Autonomic overactivity may occur -> sweating, dilated pupils, tachycardia

Question 3

Causes of delirium?

Answer 3

Alcohol - intoxication / withdrawal
Endocrine - Hypo/hyper thyroid / glycaemia
Metabolic - hypoxia, renal/hepatic system failure
Nutritional - B1, B12 / Folate deficiency
Intracranial - trauma, CVA, Haemorrhage, epilepsy, infection
Extra-cranial infection - UTI, Pneumonia, septicaemia
Iatrogenic - Chemo->septicaemia, sedatives, surgery (anaesthetics, analgesics, blood loss)

Question 4

DD of delirium

Answer 4

Mania, depression, stress response, dissociative

Question 5

Delirium vs dementia 
Time course
Natural hx 
Consciousness
Thoughts
Hallucinations

Answer 5

Delirium
Rapid (hrs-days) 
Fluctuating 
Clouded consciousness 
Vivid, complex muddled thoughts 
V common (usually visual hallucinations) 

Dementia 
Slow (months-years) 
Slowly progressive 
Alert
Usually impoverished thoughts 
1/3 have auditory / also visual

Question 6

Seems like dementia but cognition is fluctuating more like delirium what is it likely to be?

Answer 6

Lévy body dementia

Question 7

Investigations in delirium

Answer 7

Mental state assessment. - MMSE, MoCA, Addenbrookes
Physical exam - focal neurology / signs of trauma
Bloods - FBC - anaemia, macrocytosis, leukocytosis
-ESR - infection
-U&E - dehydration / electrolyte imbalance
-Glucose
-Thyroid / liver function
-Calcium, folate, B12
-VDRL - syphilis
Mid stream urine
CXR
CT / MRI
EEG - if epilepsy is a differential

Question 8

Once you have detected the cause of delirium you can treat it accordingly, What can you do if the Pt is distressed and is at risk to others/self?

Answer 8

Short term <1wk antipsychotic / benzodiazepines

-don’t give this in dementia

Question 9

What other aspects of management for delirium?

Answer 9

Maximise orientation - treat sensory impairment
clear sings / clocks / calendars / lighting
Staff can regularly explain

Prevent causes - polypharmacy, constipation/dehydration, infection (eg avoid catheters)
Assess for hypoxia, anaemia and maximise SaO2

Promote wellbeing - Encourage mobilisation, diet, sleep patterns
Pain control
Social interaction / activities

Question 10

Diagnosis of dementia

Answer 10

Multiple cognitive defects Eg memory, orientation, comprehension, reasoning, judgement

-> Impairment in ADLs Eg washing, dressing, money handling

+Clear consciousness

Question 11

Egs of cortical dementia’s and the brain areas affected

Answer 11

Alzheimer’s, Lewy body, FTD

Cerebral cortex

Question 12

Sx of cortical dementia’s

Answer 12

Memory, dysphasia, visual-spacial, problem solving, reasoning

Question 13

Eg of subcortical dementia’s and brain areas affected

Answer 13

Parkinson’s dementia, Huntington’s dementia, AIDS dementia, alcohol related
Basal ganglia + thalamus

Question 14

Sx of subcortical dementia’s

Answer 14

Psychomotor slowing, impaired memory retrieval, depression, apathy, personality change
Language relatively preserved

Question 15

Features of Alzheimer’s brain

Answer 15

Shrunken -> sulcal widening + enlarged ventricles

Question 16

What happens to amyloid precursor protein in Alzheimer’s ? How does this lead to neural death / dysfunction

Answer 16

Cleaved by secretase -> Abeta

• > Toxicity, inflammation, oxidative stress, Tau dysfunction + Neurofibrillary tangle (NFT) formation
• > Neural death / dysfunction

Question 17

What gene codes for secretase constituents

Answer 17

Presenilin 1&2

Accounts for lots of early onset

Question 18

Features of vascular dementia?

Answer 18

Patchy cognitive impairment with Sx in a stepwise and focal manner
(Often a mixed picture with Alzheimer’s )