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Gen Med: Geriatrics > Delirium vs. Dementia > Flashcards

Delirium vs. Dementia Flashcards

1
Q

Define dementia

A
  1. Decline in thinking, social, and functional abilities
  2. Not all dementias start with memory loss
  3. Brain Changes: destroys the nerve cells in the brain
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2
Q

What are signs of typical aging?

A
  1. Complaining about memory loss; can provide detailed examples of forgetfulness
  2. Occasional word searching
  3. May pause to remember directions, doesn’t get lost in familiar locations
  4. Remembers important events
  5. Conversational skills intact
  6. Interpersonal social skills intact
  7. Continues to enjoy activities
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3
Q

What are signs of early dementia?

A
  1. May complain about memory loss if asked; cannot recall specific instances
  2. Frequent word-searching and substitutions
  3. Gets lost in familiar locations, takes excessive time to return home
  4. Declines in memory for recent events
  5. Decline in conversational skills
  6. Socially inappropriate behavior
  7. Loss of interest in activities
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4
Q

What are the 4 most common types of dementia?

A
  1. Alzheimer’s Dementia
  2. Dementia with Lewy Body
  3. Vascular Dementia
  4. Fronto-temporal lobe Dementia
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5
Q

What are the risk factors for dementia?

A
  1. Age
  2. Family History
  3. Head Injury
  4. Lifestyle
  5. Fewer Years of Education
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6
Q

How is dementia diagnosed?

A
  1. Mental status testing
  2. Lab Work
  3. Brain Imaging
  4. Clinical Picture/History
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7
Q

What are the community and health resources for dementia?

A 
1. Community-Based
A. Office for Aging
B. Associations such as The Alzheimer’s Association
C. Services such as attorney, Meals on Wheels
D. Day Care
2. Health Care
A. Geriatric/memory care specialists
B. PT/OT
C. Home Care
D. Other health care members
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8
Q

What needs to be included in the goals of care discussion?

A
  1. What would the patient want
  2. Living situation
  3. Quality of life versus quantity of life
  4. Tube feeding
  5. DNR/DNI
  6. MOLST
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9
Q

What is the most common type of dementia?

A

Alzheimer’s

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10
Q

What is the prognosis for alzheimer’s?

A
  1. About 6 – 12 years after diagnosis/symptom onset

2. No Cure

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11
Q

What is the pathophys of alzheimer’s?

A
  1. Plaques outside nerve cells
  2. Tangles inside nerve cells
  3. Nerve cells die
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12
Q

What preventative measures may be taken for alzheimer’s?

A
  1. Lifestyle changes may help prevent or delay declines

2. Nothing definitive

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13
Q

How are genetics relevant to alzheimer’s disease?

A
  1. APOE Combines with lipids to form lipoproteins
  2. Carry cholesterol/fats through bloodstream
  3. Major component of VLDLs
  4. Major alleles: e2, e3, e4
  5. E4: associated with increased numbers of amyloid plaques
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14
Q

what is Presenilin 1 and why is it important to alzheimer’s disease?

A
  1. Protein, one part of a complex called gamma secretase
  2. Cleaves (cuts apart) other proteins into peptides (called proteolysis)
  3. Processes amyloid precursor protein (APP) into smaller peptides
    A. Soluble amyloid precursor protein (sAPP)
    B. Several versions of amyloid-βprotein
  4. Defective presenilin 1 interferes with processing APP
  5. Leads to overproduction of longer, toxic version of amyloid-βprotein
    A. Build up, forming amyloid plaques
  6. Seen in early-onset Alzheimer’s in 70% of cases
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15
Q

What are the sxs of early alzheimer’s dementia?

A
  1. Short term memory loss/thinking changes
  2. Forget recent events
  3. Problems doing usual routines
  4. Apathy
  5. Depression
  6. Decreased insight
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16
Q

What are the sxs of moderate alzheimer’s dementia?

A
  1. Problems with communication
  2. Increased confusion
  3. Poor judgment
  4. Behavior changes
  5. Problems with Basic 6. Activities of Daily Living
  6. Impaired Learning
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17
Q

What are the sxs of late alzheimer’s dementia?

A
  1. Difficulty speaking
  2. Difficulty completing basic tasks even with assistance
    A. Difficulty swallowing
    B. Difficulty walking
    C. Difficulty with toileting
  3. Increased risk of falls
    A. Tremor or shaking is not common in Alzheimer’s
    B. Gait (walking) and balance problems increase
  4. Declining bodily functions
  5. 24 hour supervision needs
    A. Most Alzheimer’s patients (like most dementia patients) don’t live in nursing homes
    B. There are other options
    C. Most live in the community
    Home
    D. Assisted living (DEFINE)
    E. Senior apartments
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18
Q

What are the sxs of the end stage alzheimer’s dementia?

A
  1. Complete dependency
  2. Comfort Measures
    A. Managing anxiety
    B. Managing pain
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19
Q

What meds are indicated for dementia?

A
  1. Donepezil, galantamine, rivastigmine, memantine
  2. Mood stabilizers
  3. Antidepressants
  4. Antipsychotics
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20
Q

What Lewy body dementia?

A 
1. Covers two types of dementia
A. Dementia with Lewy Bodies
B. Parkinson’s Disease Dementia
2. Approximate number of cases in the US: 1,300,000
3. Life expectancy: 5 - 7 years
4. Second most common type of dementia
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21
Q

What changes occur with lewy body dementia?

A
  1. Cognitive issues
  2. Behavior changes
  3. Symptoms more like Alzheimer’s
  4. Completely dependent
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22
Q

What do the meds for Lewy Body dementia target?

A
  1. Cognition/thinking
  2. Parkinson’s/Parkinson’s-like movements
  3. Depression and Behavioral Disturbances
  4. Sleep Disturbances
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23
Q

What are the meds used for the cognition changes in Lewy body dementia?

A
  1. Donepezil (Aricept or Aricept ODT)
  2. Galantamine (Razadyne or Razadyne ER)
  3. Memantine (Namenda, Namenda XR)
    A. Parkinson’s—tends to improve cognitive functioning/neuropsychiatric features
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24
Q

What are the meds used for the parkinsonian movements in Lewy body dementia?

A

Carbidope-Levodopa (Sinemet)

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25
Q

What are the meds used for the depression and behavioral disturbances in Lewy body dementia?

A 
1. TCAs (Tricyclic Antidepressants-
A. Amitriptyline
B. Amoxapine
C. Desipramine (Norpramin)
D. Doxepin
E. Imipramine (Tofranil)
F. Nortriptyline (Pamelor)
G. Protriptyline (Vivactil)
H. Trimipramine (Surmontil)
2. SNRI (Selective Norepinephrine Reuptake Inhibitor)
A. Venlafaxine (Effexor)
B. Dexvenlafaxine (Pristiq)
C. Duloxetine (Cymbalta)
D. Sibutamine (Meridia, Reductil)—Marketed more widely as a weight loss drug
E. Dulolevomilnacipran (Fetzima)
3. SSRIs
A. Atypical neuroleptics: clozapine (Clozaril), quetiapine (Seroquel), aripiprazole (Ability)
B. Do not use typical antipsychotics
C. Haldol most common
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26
Q

What are the meds used for slep distrubances in Lewy body dementia?

A
  1. Particularly in Parkinson’s
    A. Melatonin
    B. Clonazepam
27
Q

What are the characteristics of vascular dementia?

A
  1. Sudden onset, many times after stroke or TIA (mini-stroke)
  2. Declines occur in stages
28
Q

What is the prognosis for vascular dementia?

A

About 2 - 10 years after a diagnosis is made or symptoms begin

29
Q

What is the pathophys for vascular dementia?

A

Blocked or damaged blood vessels

30
Q

What changes are seen in vascular dementia?

A
  1. Loss of thinking ability and other brain functions
  2. Behavior/mood changes
  3. Functional changes/problems
31
Q

How is vascular dementia prevented?

A

Maintaining a healthy lifestyle

32
Q

How is vascular dementia treated?

A
  1. Same medication used for Alzheimer’s Dementia
  2. Antidepressants
  3. Mood stabilizers
  4. Preventing repeat TIAs or strokes
33
Q

What are the general characteristics of fronto-temporal lobe dementia?

A
  1. Formerly called Pick’s Disease
  2. Approximate number of cases in the United States: 700,000
  3. Life expectancy: About 2 – 10 years after diagnosis or symptoms begin
34
Q

What are the causes of fronto-temporal lobe dementia?

A
  1. Portions of the brain shrink too much

2. Protein forms inside nerve cells

35
Q

What are the changes seen in fronto-temporal lobe dementia?

A
  1. Cognitive
  2. Behavior
  3. Function
36
Q

What are the meds used in fronto-temporal dementia?

A
  1. Mood stabilizers
  2. Antipsychotics
  3. Antidepressants
37
Q

How can the sxs of dementia be managed?

A
  1. Simple Instructions
  2. Physical Activity
  3. Allow the patient
    A. To make decisions about own care
    B. To make own decisions about things like clothes, food
    C. To do as much as they can for
    themselves
  4. Printed media is not a crutch
  5. See a health care provider for all sudden changes
  6. Do not use the word “no”
  7. If patient gets agitated and is safe, back off
  8. Provide memory cues for important events/people in a person’s life
  9. Redirection
  10. Offer to help, but don’t insist
  11. Remember tone of voice/body language
  12. It’s ok to fib
  13. Help people talk about their lives
  14. Ask for help rather than giving instructions
38
Q

What are pearls for dementia?

A
  1. Increasing agitation can indicate a medical issue such as infection
  2. Poor nutrition and lack of sleep
  3. Establish routines
39
Q

Define delirium

A
  1. Temporary confusion and disorientation caused by underlying medical problems, drug toxicity, or environmental factors
  2. Fluctuating level of consciousness
  3. Reduced ability to focus, sustain, or shift attention
40
Q

How does delirium affect the pt outcomes?

A
  1. 10-fold risk of death in hospital
  2. 3 – 5 fold increased risk of nosocomial complications, prolonged stay, postacute SNF placement
  3. Poor functional recovery/increased risk of death up to 2 years post-discharge
  4. Persistence of delirium = poor long term outcomes
41
Q

What is the onset in dementia vs. delirium?

A
  1. Delirium: Sudden, abrupt, depends on cause

2. Dementia: Insidious/slow and often unrecognized; depends on cause

42
Q

What is the course in dementia vs. delirium?

A
  1. Delirium: fluctuating

2. Dementia: Long-term, symptoms progressive

43
Q

What is the awareness in dementia vs. delirium?

A
  1. Delirium: Impaired; sudden onset

2. Dementia: Becomes impaired gradually

44
Q

What is the attention in dementia vs. delirium?

A
  1. Delirium: disturbed, sudden onset

2. Dementia: Becomes impaired gradually

45
Q

What is the memory in dementia vs. delirium?

A
  1. Delirium: Poor working memory/immediate recall

2. Dementia: Becomes impaired gradually

46
Q

What is the delusions in dementia vs. delirium?

A
  1. Delirium: Often short-lived/changing

2. Dementia: more fixed

47
Q

What is the sleep disturbances in dementia vs. delirium?

A
  1. Delirium: fragmented

2. Dementia: sleep-wake reversal

48
Q

What are the most common causes of delirium?

A
  1. Dementia
  2. Electrolyte disorders
  3. Lung, liver, heart, kidney, brain
  4. Infection
  5. Rx drugs
  6. Injury, pain, stress
  7. Unfamiliar environment
  8. Metabolic
49
Q

How is delirium diagnosed?

A
  1. Under recognition = major problem

A. Nurses recognize/document 95% sensitivity/specificity

50
Q

What are the criteria in the Confusion Assessment Method for Acute Onset and fluctuating course?

A

Is there evidence of an acute change in mental status from baseline? Did the abnormal behavior fluctuate during the day or increase and decrease in severity?

51
Q

What are the criteria in the Confusion Assessment Method for inattention?

A

Did the patient have difficulty focusing attention?

52
Q

What are the criteria in the Confusion Assessment Method for disorganized thinking?

A

What the patient’s thinking disorganized or incoherent?

53
Q

What are the criteria in the Confusion Assessment Method for altered level of consciousness?

A

Normal = alert; Drowsy, easily aroused = lethargic; Hyperalert = vigilant; Difficult to arouse = stupor; Unarousable = coma (Abnormal if anything other than alert)

54
Q

what are the criteria for diagnosis of delirium using the confusion assessment method?

A

Requires presence of #1 and #2 and either #3 or #4

55
Q

What needs to be monitored when using namenda?

A

Kidney function

56
Q

Why might namenda be used in mild alzheimer’s?

A

Cardio protective?

57
Q

How is delirium managed?

A
  1. Optimize environment
  2. Personal belongings
  3. Remove indwelling devices ASAP
  4. Encourage proper sleep hygiene
  5. Prevent/treat urinary retention/constipation
  6. Address contributing factors
  7. Treat underlying cause
  8. Encourage adequate oral intake
  9. Education
  10. Ensure patient has dentures, glasses, hearing aids
58
Q

How is pain in managed in delirium?

A
  1. If can swallow and not contraindicated: Tylenol routinely and oxycodone 5 mg PRN
  2. Other methods as needed
59
Q

How is agitation treated in delirium?

A
  1. Mood stabilizers
  2. Antipsychotics (in limited circumstances)
  3. CIWA protocol if alcohol related
  4. Appropriate bowel regimen
60
Q

What are the keys to effective management of delirium?

A 
1. Interdisciplinary effort:
A. Providers
B. Nursing staff
C. Family
D. Therapists
2. Multifactorial approach is best
3. Failure to diagnose and manage delirium = costly, life-threatening complications, loss of function
61
Q

What is the delirium protocol?

A
  1. Private room if possible.
  2. Quiet time, NO vitals, NO non emergent lab draws from 9 PM to 6AM.
  3. Television from 8 AM to 8 PM.
  4. NO changing rooms after 9 PM.
  5. Ensure patient has glasses, hearing aids, pocket amplifier, dentures.
  6. Redirect and re-orient as needed.
  7. Promote day/night orientation.
  8. White board with names of staff, day, date and plan.
  9. Consistent staff whenever possible.
  10. Activity (if patient is allowed to get out of the bed); OOB to chair 3x daily for meals.
  11. Assist with tray set up and meals.
  12. Offer snacks between meals.
  13. Offer fluids every 1-2 hours if not NPO.
  14. Bladder scan if no Urine output for 6 hours.
  15. Notify House officer if patient has not had a BM for 3 days.
62
Q

What is included in the acute care for the elderly team?

A
  1. Mandatory screening on majority of patients ≥ 75
  2. Admitted from nursing homes
  3. Diagnosis of dementia
  4. Others as needed/requested
63
Q

What are the goals of acute care for the elderly team?

A
  1. Reduce risk of delirium/minimize impact of delirium
  2. Reduce length of stay
  3. Address phamacological issues
  4. Reduce risk of physical/functional decline
  5. Help with defining goals of care

Gen Med: Geriatrics (5 decks)

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