Delirium, Dementia, Alzheimer Flashcards
Cognitive failure
dysfunction/loss of cognitive function
ex: delirium (acute)
ex: demential (chronic)
Delirium
acute, transient (comes and goes), flunctuating changes in mental state; attention, cognition & consciousness levels (lethargy-> drowsy -> agitation), usually reversible
Incidence
15-50% amongst hospitalized elders, post surgery, etc
signs & symptoms (3/7)
- shifting levels of attention-difficulty focusing
- altered level of consciousness (LOC)-less aware environment
- fluctuating changes of cognition-ex: transient (temporary) memory loss, disorganized
- sensory misperceptions common (illusions), hallucination
- disturbed psychomotor activities (restlessness, picking at things)
- sleep-wake cycle disturbances-symp. worsen at night
diagnosis
- run test & imaging search for causes, hx
- immediate medical evaluation & treatment
- can be life threatening
- R/O (rule out) dementia & depression
- neurological signs & symptoms (ex:paralysis), which would not show right away
Key diagnostic aspects, 3
- acute onset: s&s develop over hours/days
- fluctuating s&s (during course of day)
- evidence of med. condtn., toxin, w/drawal (ex: potentionlly reversible)
causes of delirium, 3
- drugs:
- analgesic (narcotics, etc)
- anticholiergics (cardiovascular & antiparkinsons drugs etc)
- psychotropic drugs (antidepressants, steroids)
- prescribed, abused, overdose, or w/drawal - Infection:
- Urinary tract infection (UTI),
- pneumonia - dehydration & causes of decrease cardiac output (ex: acute blood loss
- MI (heart attack)
- -stroke: high bl. pressure, TIA)
-metabolic disorders (malnutrition
-hypoxia etc)
-intoxicants (alcohol)
-hypo/hyperthermia
acute psychoses
predisposing factor
- aging
- male
- damaged brain (head injury, CVA, pre-existing dementia)
- impaired sensory fnctng. & sensory deprivations (hospital light on all night/uncomfortable hospital beds) (anyone who gets older)
precipitating factors (causes)
*-immobilization, fractures (death nail for heart attack, weaker everyday when staying in bed)
-drugs
-infection
-dehydration
-sleep deprive, shock, exhaustion
-malnutrition, under-nutrition
transfer to unfamiliar environment
-psychomotor stress (restraints)
-decreased sensory stimulation
-fecal impaction
Therefore, delirium common complication of hospitalization
prognosis
- increase morbidity & mortality
- 35-40% hospitalized elders experiencing delirium die w/in a year due to vulnerability from serious health problems
prevention
- prepare OA for changes in location
- place familiar objects surrounding
- maximize sensory input (lighting, clocks, calendars)
treatment
- reverse underlying cause
- medications for delusions
- supportive: restore sleep/wake cycle, reassurance
Dementia (general)
a clinical syndrome involving a sustained loss of intellectual funct. & memory loss severe enough to cause dysfunction in daily living (de=loss, mentia=mind)
Key features
- gradually progressing course (over months & years)
- no disturbance of consciousness (vs. delirium)
reversible dementia
- R/O reversible & potentially reversible; 20% of all dementia
- responds to tx
- damage may be reversed
causes of potentially reversible dementia
- drugs toxicity ex: alcoholism (acute brain reaction to acute lack of vit. B-1) common, causes delirium, dementia, depression, falls
- heavy metals (lead), organic poison (carbon monoxide)
- Trauma
- Infection (viral, HIV)
- autoimmune disorders (multiple sclerosis)
dementia (irreversible)
a chronic, irreversible, progressive, incurable structural, damage to brain tissue
Types of dementia, 3
- degenerative disease of the CNS (AD)
- vascular dementia (Multi-infarct dementia MID)
- Mixed: AD & MID; Korsakoff Syndrome
AD (degenerative disease of the CNS)
-2/3 of dementia in geriatric population, onset >65, F>M
Lewy Body Dementia:
- > DLB=Dementia of Lewy Body type [also occur in late PD]
- > Lewy Body (clumps of specific protein, don’t need to know
- > 3rd most common after AD & MID, onset
- > onset >60, M>F
- > lewy body proteins=decreased & fluctuating alertness, halluc., PD signs
Frontotemporal Lobe (FTD,aka Pick’s disease):
- > common cause young-onset dimentia, onset <65, M=F, ->Tau proteins in brain,
- > 50% heredity
- > less memory affected, variants: increased behavior & increased language impact
L.A.T.E (limbic-predominant age-related TDP-43 Encephalopathy)
->recently discovered on autopsy, similar to AD
Vascular dementia:
Multi-infarct dementia (MID)
- 15% of dementias in geriatirc population (M>W, >60)
- course: step-wise deterioration
- more changes of HBP (high blood pressure), neurological signs (ex: unilateral weakness, sensory deficit, loss of speech, gait earlier than AD)
- occlusive cerebrovascular disease
Korsakoff syndrome (Mixed AD & MID)
chronic memory disorder often proceed by acute Wernicke Encephalophaty=severe lack Vit B-1, ex: due to alcohol, infection, AIDS, cancer, malabsorption
AD (in details)
a progressive neurological disease which affects the brain, causing mental deterioration
incidence
- most common form of irreversible dementia,
- 2/3rds of dementia in geriatric population
- 4th leading cause of death in OA (after heart disease, cancer & stroke)
- single major cause of institutionalization of OA
- by 85, 25% of popul., by 90, 50% of popul.
pathophysiology
presence of neurofrillary tangles, prions (misfolded proteins) & beta-amyloid deposits leading to neuron death & formation of plaque
etiology
unkown
risk factors
- family hx (5-15% have familial form, half can have ‘early onset’ before 60)
- increasing age
- genetic link
- previous head injury (brian damage=lose neurons)
- female 2:1 (live longer)
prevention
possible protective factors:
- increase exercise
- control & decrease hypertension
- decrease cholestrol
Diagnosis
Hx & lab tests:
- -Mental status screening (mini mental state examination)
- assess function, sensory & physical impairments
- r/o reversible dementias, delirium, depression, MID, normal aging change of cognition
- Mild Cognitive impairment (MCI)
diagnostic criteriafor AD
multiple cognitive deficits manifested by:
- memory impairment; learning & retaining new info (missed appointments) and one/more:
- > aphasia, language disturbance
- > apraxia, impaired ability to perform motor activities despite intact motor funct.
- > agnosia, failure to identify objects despite intact sensory function ex: can’t tell key in pocket
- > impaired executive funct., handling complex task (balancing chequebook)
deficits cause SEVERE impairments in social/occupational functioning, which represent a SIGNIFICANT DECLINE form previous level of functioning AND there is continuous cognitive decline (no disturbances of consciousness)
Onset/course
- insidious,
- age 65-84,
- continuing progressive, cognitive decline (2-20) years until death
symptoms: behavior & other pathological (may not have all)
affective disturbances: tearfulness, depression
paranoid delusional (false belief), all due to memory loss:
- ppl are stealing from them
- house is not one’s home
- spouse is an imposter
- abandonment
- infidelity
hallucinations: visuel & auditory incorrect perception
activity disturbances: wondering, purposeless activity (cognitive abulia), frequent repetitive activities, pacing
aggressivity: verbal outburst, physical outburst
diurnal rhythm disturbance: day/night disturbance, multiple awakenings-pacing
anxieties & phobias
Reisberg’s global deterioration scale, 3 stages
mild stage (don’t know have AD):
- > no memory prob.,
- > normal aging (memory lapse, forgets familiar names & locations)
- > mild cognitive decline (mild cognitive impairment=MCI, not all progress to AD) - mild forgetfulness noticeable to others
moderate stage:
- > moderate- mild/early AD diagnosed (course 2 years) can live in community w/ financial superv.
- > moderately severe cognitive decline (mid stage AD) - needs assistance (1 1/2years) unsafe live alone & drive, need supportive safe home
mod-severe AD - need help w/ ADL (2 1/2 yrs), unsafe judging bath temperature, need full-time supervision, may need placement, forget spouse name, more delusion, agitation and rigidity
severe stage
- > late stage AD
- > lost verbal abilities lost (50% dead after 2-3 yrs, some survivefor 7 yrs)
- > unable to walk/use toilet/feed self
- > placement needed
- > rigidity causes joint contractues in nonambulatory (unable to walk) patients
- > pneumonia (aspiration) frequent cause of death
very severe
- > lost all verbal abilities
- > incontinent of urine
- > lose basic psychomotor skills (walk)
- > brain no longer able tell body what to do
treatment principles
- no cure, treatment is supportive
- prolong first stages, when “person” still there, and try to postpone final stage
- drugs to try and enhance cognitive funct.n
- major support for caregiver
general management (Rx) for AD & dementia, 8
- optimize patient’s FUNCTION
- assess & adapt environment-> supportive measure: ex: lighting
- socialization, reminiscence, communication-> groups
- encourage physical activity, exercise & mental activity -> PT/OT, groups - identify & manage complications-ensure safety
- dangerous driving-> screening
- malnutrition-> meals-on-wheels
- wandering, getting lost-> safe housing - provide ongoing care (assess medical & cognitive condition)
- colinestrerase inhibitors - provide medical info to patients & family (pronosis, end of life)
- education - social service support (caregiver, ADL, Legal , financial)
- support groups - family counselin for anger, guilt, ethical concerns
- stigma
- use sensitive, person-centred terms
- carer, person with dementia, clothing protector, incontinence product - Music therapy
drugs to aid cognition & functn.
Cholinesterase inhibitors (eacrine, shown some temproary help w/ cognitive function)
guidlines for workn w/ dementd persons
- respect, accept ‘where’ client is (not reality orientation)
- simple activities form past (music, photographs, stuffed animal)
- risk falls later stages
