Delirium & Dementia Flashcards
Compare and contrast delirium and dementia, include:
- Onset
- Course
- Consciousness
- Cognitive impairment, distractability & inattention
Delirium
- Acute onset
- Flucutating course
- Altered level of consciousness: could be increased (hyperalalert: agtiated & confused), unchanged or decreased (hypoalalert- drowsy & withdrawn)
- Inattention and distractability
Dementia
- Chronic onset (months-years)
- Progressive deterioration
- No disorder of alertness or consciousness
- Cognitive impairment interferes with activities of daily living
Dementia and derlium can co-exist; true or false?
True (a pt with dementia is more at risk of delirium)
State some risk factors for developing delirium
- Dementia
- Multiple comorbidities
- Physical frailty
- Oler age
- Sensory impariments
State some potential precipitating factors/causes of delirium
- Drug initiation
- Urinary retention
- Constipation
- Hypoxia
- Systemic infection
- Metabolic derrangement
- Surgery
- Pain
- Brain disorders e.g. stroke, seizure
- Systemic organ failure
*
How long does it take for delerium to be resolved?
Time varies between individuals but it can take anywhere up to 3 months to resolve. Some people never get back to their baseline.
What do you need to know about the pt to help you determine if the pt has delirirum?
Need to know their baseline; if you can’t get from pt get a collateral history
What screening tool can you use to diangose cognitive impairment?
AMT10
- Age
- Time
**** At this point give pt the address you want them to recall
- Year
- Date of birth
- Pts home address
- What jobs do these peopel do- show two photos
- When did WW1/WW2 start
- Current prime minister
- Ask to recall address given earlier on
Score 1 point for each that you get correct. Scores <7 suggest some cognitive impairment
The Confusion Assessment Method is 94-100% sensitive and 90-95% specific for delirium if the 3 criteria are met; state these 3 criteria
- Acute onset and fluctuating course
- Inattention
- Disorganised thinking or altered level of consciousness
What investigations would you do for someone with delerium, include:
- Bedside
- Bloods
- Imaging
*think about which are first line and which are second line
Bedside
- Plasma glucose
- Urinalysis
- ECG
- ABG
- Cultures (blood, urine, sputum)
- Bladder scan
- EEG
Bloods
- FBC
- U&Es
- LFTs
- TFTs
- CRP
- Calcium, B12, folate
- Toxicology screen
Imaging
- CXR
- CT/MRI head
State some differential diagnoses for delirium
- Dementia
- Focal neurological syndromes e.g. Wernicke’s encephalopathy, frontal lobe lesions
- Non-convulsvie status epilepticus
- Primary psychiatric illness e.g. depression, mania, schizophrenia
Dicuss the management of delirium, think about:
- Treating the underlying cause
- Managing the environment
- Monitoring
- Drug management
Treat underlying cause
- Polypharmacy = medication review
- Pain = analgesia
- Constipation = laxatives
- Infection = antibiotics
- Corrrect electrolytes
Managing the environment
- Involve family
- Clocks and calenders
- Lighting
- Promote nightime sleep
- Correct sensory impairment
- Keep mobile & active
- Avoid multiple rooms, staff etc…
- Minimise noise, restraints etc..
Monitoring
- Vital signs
- Bowels
- Nutrition & hydration
- Pressure areas
- Electrolytes
- Response to Abx
- Re-explore diagnosis if not improving
Drug management
Drugs shold be avoided if possible and only given when pt is at significant risk to themselves or others:
- Haloperidol (oral or IM)
- Lorazepam (oral or IM)
*NOTE: drugs should be commenced at lowest effective dose. Avoid haloperidol in parkinsons
State some potential complications of delirium
- Increased mortality
- Prolonged hospital admission
- Higher complication rates
- Institutionalisation
- Increased risk of developing dementia
Dementia has no agreed defintionl; however, try and describe what dementia is in your own words
Progressive, irreversible cognitive decline (involving impariment of memory and other higher cortical functions) which leads to an impaired ability to complete everyday taks.
Briefly remind yourself of the different types of dementia (for more detial see Sem 4 Neuro lectures)
- Alzheimer’s
- Vascular dementia
- Lewy body dementia
- Frontotemporal dementia
- AIDS-dementia complex
- Huntingdon’s disease
- Alcohol related dementia
- CJD
State some risk factors for developing dementia
NOTE: risk factros vary dependent on type of dementia
Modifiable
- Smoking
- Alcohol
- Atherosclerosis
- High cholesterol
- Obesity
- Low standard education
Non-modifiable
- Genetics
- Age
State some key differentials you must rule out when querying if a pt has dementia
- Mood disorders e.g. depression (pseudodementia)
- Metabolic e.g. hypothyroid, vit B12 deficiency
- Trauma e.g. subdural haematoma
- Tumour e.g. glioblastoma
- Posions e.g. heavy metal, recreational drugs
- Nutrition e.g. thiamine deficiency, B6 deficiency
- Medication e.g. steroids, antidepressants
- Other e.g. normal pressure hydrocephalus
State some symptoms of dementia
- Memory loss
- Inability to manage complex tasks
- Difficulty with language and words
- Altered behaviours
- Altered orientation
- Altered ability to self care
- Altered reasoning
- Difficulty recognising familiar faces (agnosia)
What is pseudodementia?
Condition that appears similar to dementia but does not have the same neurological roots/cause as dementia; often associated with mood disorders.
State some causes of ‘reversible dementia’ (i.e. conditions that may present like dementia but it treated in timely manner they will resolve)
Neurological
- Subdural haematoma
- SOLs
- Normal pressure hydrocephaus
- Infection e.g. HIV, syphilis
Endocrine
- Hypothyroidims
- Hyperparathyroidims
- Addison’s
- Cushing’s
Nutrition
- B1 (thiamine)
- B12/folate
- B3 (niacin)
Discuss what cognitive tests you could do if you suspect dementia
- MMSE
- MoCA (montreal cognitive assessment)
- ACE-R (revised Addenbrooke’s cognitive examination)
State the 5 A’s of alzheimers dementia
- Amnesia (inability to recall facts or previous experiences)
- Agnosia (inability to recognise familiar faces)
- Apraxia (difficulty with motor plannin & performing tasks)
- Aphasia
- Abstract thinking
What investigations would you do if you suspect dementia, include:
- Bedside
- Bloods
- Imaging
*Most of investigations centred around finding alernative explanation. For each, justify why.
Bedside
- Urine culture
- Glucose
Bloods
- FBCs
- U&Es
- LFTs
- TFTs
- Calcium
- B12, folate, niacin
- VDRL (for neurosyphilis)
- CRP
Imaging
- CT or MRI head
Discuss the management of dementia- consider how management varies for different types of dementia. Include pharmacological and non-pharmacological treatment
Pharmacological
- Alzheimer’s: acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine), NDMA antagonists (e.g. memantine)
- Dementia with Lewy bodies: same as Alzheimer’s
- Vascular: manage risk factors
- AIDS complex dementia: treat HIV
Non-pharmacological
- Orientation
- Reassurance
- Routine
- Complementary therapies e.g. music therapy, art therapy etc…
- Home adaptations
- Social support
State some potential complications of dementia
- Cause harm to themselves
- Increased mortality
- Strain on family members/carers
- Institutionalisation
- Pneumonia due to aspiration
- Falls
- Weight loss
- UTIs
