Delirium, dementia, UTI Flashcards
Name 9 common causes of confusion.
Dementia Delerium Subdural haematoma Stroke Hypoglycaemia Hypercalcaemia Dehydration Psychiatric disturbance Drugs/medications
Name 4 types of drugs which cause confusion.
Steroids
Opioids
Sedatives
Anticholinergics
What important questions should you ask in a confusion history?
Duration - ?dementia
Associated - cough/fever/dysuria ?infection , constipation/abdo pain/thirst/polyuria ?hypercalcaemia
Falls - subdural haematoma
PMH - RF for vascular dementia, diabetes ?hypoglycaemia
Medications - types, compliance
SH - smoking ?vascular , alcohol ?Wernicke’s encephalopathy
List the classifications on the Clinical Frailty Score.
1 very fit - fittest for their age
2 fit - no disease but little exercise
3 managing well - controlled medical conditions
4 vulnerable - symptoms limit daily living but are independent enough
5 mildly frail - need help with IADL
6 moderately frail - need help with all activities
7 severely frail - completely dependent for personal care
8 very severely frail - approaching end of life, wouldn’t recover from minor illness
9 terminally ill - <6 months to live
Which systems should you examine in an patient with confusion?
ALL OF THEM
Which blood tests would you order for a confused patient?
FBC - ?infection, anaemia, malignancy U&Es - ?AKI, electrolyte imbalance, dehydration Bone profile - ?hypercalcaemia CRP/ESR - ?infection, inflammation LFTs - ?liver failure, secondary encephalopathy Coag/INR - blood thinning meds TFTs Haematinics - low B12/folate Glucose
Infection is a common cause of a confused state. Why would thrombophilia be present in this case?
They help neutrophils migrate to the site of infection and by binding to certain bacteria/fungi themselves to internalise and kill the pathogens.
List the common causes of delirium.
Constipation Hypoxia Infection Metabolical disturbance Pain Sleeplessness Prescriptions Hypothermia/pyrexia Organ Dysfunction Nutrition Environmental changes Drugs (OTC, illicit, recreational, alcohol)
What are the typical complaints in a patient with a UTI?
urethral burning with urination pelvic pain increased frequency of urination increased urgency of urination fever chills and rigors (atypical: lethargy, reduced eating and drinking, decreased mobility, falls, agitation, incontinence, agitation)
A patient presents to the GP with increased frequency and urgency of urination. On examination they complain of pelvic pain and have a fever. What is the most likely diagnosis at this stage? And what other symptoms may be found in the history?
Urinary tract infection
urethral burning with urination
chills and rigors
confusion in elderly patients
In patients with more systemic symptoms in a ?UTI, consider whether the pathogen has spread to the kidneys. Symptoms that may suggest pyelonephritis are:
fever, flushed skin, back pain or renal angle tenderness, nausea, vomiting
What are the two most common types of bacteria which cause UTI in the geriatric population?
Escherichia Coli
Klebsiella pneumoniae
What are the risk factors for adults developing UTI?
history of UTIs dementia catheter use bladder/bowel incontinence prolapsed bladder
Describe UTI pathogenesis beginning with urethral colonisation.
- colonisation of periurethral area and ascends towards the bladder
- uroepithelial penetration: bacteria replicate and form biofilms
- ascension: up ureter towards kidneys, flow of urine inhibited by bacterial toxins
- pyelonephritis: infection of renal parenchyma
- acute kidney injury: inflammatory cytokine storms leads to renal tubular obstruction and damage, resulting in interstitial oedema, can lead to interstitial nephritis and AKI
List some risk factors for the development of delirium.
Age > 65 years Cognitive impairment Severe illness Organ failure Sensory impairment Multiple co-morbidities Frailty, malnutrition, immobility Untreated pain Limb fractures Catheter use Sleep deprivation
Name and describe the three clinical sub-types of delirium.
Hyperactive: heighten arousal, restlessness, agitation, hallucinations, inappropriate behaviour
Hypoactive: lethargy, reduced motor activity, incoherent speech, lack of interest, can be confused with depression or dementia
Mixed: combination
List some appropriate strategies to support a patient with delirium.
Frequently and gently re-orientate to time, place and person as appropriate.
Introduce yourself and other staff to patient
Clear, concise communication
Ensure patient has: glasses, hearing aids and walking aids if they use them.
Encourage patient to do be independent
What is the first line treatment of UTI in a woman with no signs of pyelonephritis? (no fever or flank pain)
oral nitrofurantoin 50mg (6hrly) for 3 days
OR
oral trimethoprim 200mg (12hrly) for 3 days
When would the use of nitrofurantoin be contraindicated in UTI?
reduced kidney function eGFR <30 - give trimethroprim
What is the Sepsis 6?
- Give O2 (Aim SpO2 >94%)
- Give IV antibiotics (See local guidelines)
- Give IV fluids (If hypotensive/lactate >2mmol/L 500ml stat – caution with cardiac failure)
- Take blood cultures
- Take serum lactate
- Take Urine output measurements (may require urinary catheter)
What is dementia?
A disorder that is characterised by a decline in cognition involving one or more cognitive domains (learning and memory, language, executive function, complex attention, perceptual-motor, social cognition) - the deficits must represent a decline from previous level of function and be severe enough to interfere with daily function and independence
List the causes of dementia.
cognitive impairment, Alzheimer’s disease, vascular dementia, Lewy-body dementia, fronto-temporal
Rarer causes: Pick’s disease, alcohol related, CJD, HIV, cryptococcus, CADASIL, syphilis
What causes Alzheimer’s disease?
environmental and genetic causes
accumulation of beta-amyloid peptide - progressive neuronal damage/neurofibrillary tangles/amyloid plaques and loss of acetylcholine (neurotransmitter)
What are the risk factors for developing Alzheimer’s disease?
genetic factors Down's syndrome vascular risk factors (HTN, DM) low physical and cognitive activity ethanol (accelerated presention)
