Delirium/Dementia

Question 1

What is delirium

Answer 1

Acute confusional state seen by change in baseline behaviour of pt, may need relative’s help to see change

Question 2

Delirium presentation

Answer 2

Globally impaired cognition
Memory deficit
Disorientation/disordered thinking
Reversal of sleep/wake cycle

Question 3

Categorising delirium

Answer 3

Hyperactive (restlessness, agitation, aggression)
Hypoactive (slow, withdrawn)
Mixed

Question 4

Delirium RFs

Answer 4

> 65 yrs
Dementia/cognitive impairment
Hip #

Question 5

Delirium causes

Answer 5

Surgery/post GA
Systemic infection
Drugs/withdrawal
Metabolic/nutritional
Hypoxia/Vascular
Head injury

Question 6

Delirium management

Answer 6

Treat cause
Reorientate pt + encourage family/friend visits
Sleep hygiene + physical activity
Prevent infection e.g. remove catheters/monitoring
Review medication + sedate if risk to self/other pts

Question 7

Dementia diagnosis

Answer 7

History of decline, non-cognitive (apathy/aggression) indicates late stage
Cognitive testing, AMTS screen or similar
Examination may show physical cause/RFs
Exclude reversible/organic causes

Question 8

Dementia subtypes

Answer 8

Alzheimer’s
Vascular dementia (cumulative effect of many small strokes), don’t use memantine/AChase inhibitors
Lewy body (parkinsonism late stage), avoid antipsychotics
Fronto-temporal (executive, behavioural impairment), Pick’s disease if Pick inclusion bodies on histology

Question 9

Dementia management

Answer 9

Avoid cognitive impairing drugs
Non-cognitive symptoms e.g. agitation may respond to alternative medicines
CBT/SSRIs for depression
Assess capacity and suggest advanced directive

Question 10

Abbreviated Mental Test Score (AMTS) questions

Answer 10

(Name +) DOB
Age
Remember something to recall at end (e.g. 42 West St)
Current time
Current year
Where are they
Who am I + Who is person with me

When was WW2
Who is PM

Count backwards from 20

Question 11

AMTS score meaning

Answer 11

≤8 suggests poor cognition e.g. delirium/dementia

Question 12

Alzheimer’s disease presentation

Answer 12

Persistent progressive global cognitive impairment in >40yrs
Anosognosia - lack of insight into problems
Later irritability, mood disturbance, psychosis etc
Cognitive symptoms progressive but non-cognitive may come and go

Question 13

Alzheimer’s features

Answer 13

Accumulation of beta-amyloid peptide, amyloid plaques and neurofibrillary tangles
Loss of ACh
Neuronal loss in hippocampus, amygdala mainly

Question 14

Alzheimer’s risk factors

Answer 14

1st degree relative
Down's syndrome
Vascular risk factors
Genetic variants, APOE4 mainly and others
Depression, loneliness, smoking

Question 15

Alzheimer’s management

Answer 15

Refer to memory service
Pharm treatment (AChase inhibitors)
BP control

Question 16

Alzheimer’s early identification

Answer 16

Identify affected 25 years before onset of unequivocal symptoms with CSF beta-amyloid changes
CSF tau protein + brain atrophy 15 yrs before
Cerebral hypometabolism + impaired episodic memory 10 yrs before
Global cognitive impairment 5yrs before

Question 17

Alzheimer’s prognosis

Answer 17

Mean survival 7yrs from unequivocal symptoms

Question 18

Pharm treatments of dementia

Answer 18

AChase inhibitors
Antiglutaminergics (Memantine 5mg/24h then increase 5mg/d weekly to 10mg/12h, late stage)
Antipsychotics (unless Lewy body, Alzheimer’s or vascular dementia)
Vitamin supplementation (Vit E in AD may slow progression)

Question 19

AChase inhibitor use

Answer 19

AD and sometimes Lewy body, not in mild disease
Donepezil 5mg PO for 1 mth then doubled
Rivastigmine 1.5mg/12h increased to 3-6mg/12h
Galantamine 4mg/12h to 8-12mg/12h PO

Question 20

Neuroleptic malignant syndrome tetrad

Answer 20

Hyperthermia
Muscle rigidity
Autonomic dysfunction
Altered mental state

Question 21

Neuroleptic malignant syndrome bloods

Answer 21

Raised CK

Raised WCC