Dementia and Delirium Flashcards
Identify risk factors for DEMENTIA.
✔️ increasing age ✔️ family history of dementia (particularly early onset, < 65 years) ✔️ smoking history ✔️ alcohol history ✔️ atherosclerosis / coronary artery disease ✔️ history of traumatic brain injury ✔️ history of stroke ✔️ diabetes mellitus ✔️ down syndrome
Outline some sub-types of dementia.
✔️ Alzheimer's Disease ✔️ Parkinson's Disease ✔️ Fronto-temporal Dementia ✔️ Pick's Disease ✔️ Huntington's Disease ✔️ Vascular Dementia ✔️ Lewy Body Dementia ✔️ CJD ✔️ Wenicke's Encephalopathy / Korsakoff's Psychosis
DSMV-V Criteria for MAJOR NEUROCOGNITIVE DISEASE (DEMENTIA)
A. Significant deterioration from baseline in one or more of the following areas:
✔️ executive functioning
✔️ language
✔️ complex attention
✔️ memory and learning
✔️ motor and sensory cognition
B. Decline causes significant impairment in activities of daily living / independence with daily activities.
C. Cognitive decline does NOT occur in the context of delirium.
D. Cognitive changes are NOT better explained by another condition.
What are the FIVE areas tested by the MMSE?
- orientation
- attention
- memory and learning
- language
- visuo-spatial awareness
How is the MMSE scored?
Maximum score is 30.
Mild Cognitive Impairment: 20 to 25
Moderate Cognitive Impairment: 10 to 20
Severe Cognitive Impairment: < 10
N.B. the MMSE is NOT a diagnostic tool; screening tool for cognitive decline / reduction from baseline; results may prompt further investigation.
Outline what the FRONTAL ASSESSMENT BATTERY is and how it is interpreted.
The FAB is a screening tool that can be used to differentiate between pronto-temporal dementia and dementia of Alzheimer’s type (DAT) in patients that demonstrate mild cognitive impairment on the MMSE (score > 24).
The maximum score of the FAB is 18. A higher score is associated with higher cognitive functioning.
Identify some investigations that would be appropriate for the work-up of a patient with cognitive decline.
✔️ history and physical examination ✔️ urine dipstick and MCS ✔️ FBC and WCC ✔️ inflammatory markers ✔️ UECs ✔️ CMP ✔️ eLFTs ✔️ fasting lipds ✔️ blood glucose level ✔️ iron and B12 + folate studies ✔️ syphilis and HIV serology ✔️ CT head (non-contrast) ✔️ CXR to exclude respiratory pathology for delirium
CHOLINESTERASE INHIBITORS ✔️ example drug ✔️ indication ✔️ mechanism of action ✔️ important consideration
EXAMPLE DRUG - donepezil 5mg PO
INDICATION - cognitive decline / memory loss
MECHANISM OF ACTION - inhibition of the enzyme that breaks down acetyl choline, resulting in increased A-Ch levels within the brain; helps to improve cognitive function and awareness; maintains baseline for ~12 months, however, has minimal impact on the underlying disease process
ANTIPSYCHOTICS ✔️ example drug ✔️ indication ✔️ mechanism of action ✔️ important consideration
EXAMPLE DRUG - olanzapine, risperidone
INDICATION - psychotic features (e.g. delusions, hallucinations)
MECHANISM OF ACTION - inhibits over-activity of dopamine within the mesolimbic pathway by inhibiting D2 receptors
IMPORTANT CONSIDERATIONS - do NOT prescribe FGA to elderly patients; increased risk of EPSEs
BENZODIAZEPINES ✔️ example drug ✔️ indication ✔️ mechanism of action ✔️ important consideration
EXAMPLE DRUG - lorazepam, oxazepam, temazepam (these drugs are indicated in elderly patients because they are NOT metabolised in the liver)
INDICATION - agitation / aggression
MECHANISM OF ACTION - agonist of the GABA-a receptor within the brain
IMPORTANT CONSIDERATIONS - do not prescribe for > 14 days; be aware of withdrawal and causation for delirium
SSRIS ✔️ example drug ✔️ indication ✔️ mechanism of action ✔️ important consideration
EXAMPLE DRUG - fluoxetine, duloxetine
INDICATION - depressive features / mood disturbances
MECHANISM OF ACTION - inhibition of reuptake of serotonin and / or adrenaline; improves mood and alertness
IMPORTANT CONSIDERATIONS - do NOT prescribe antidepressant that inhibits acetylcholine (e.g. TCAs).
Outline non-pharmacological management of dementia.
✔️ create a familiar environment ✔️ cues for orientation (e.g. clocks, calendars, photos) ✔️ regular routine ✔️ music therapy ✔️ brain training (e.g. sudoku)
Define DELIRIUM.
DELIRIUM - a transient and reversible decline in attention, awareness and cognition.
Outline differential diagnoses for DELIRIUM.
D - drugs –> withdrawal, intoxication, medication interactions
E - electrolytes –> hyponatremia
L - lack of oxygen –> anaemia, congestive cardiac failure, pulmonary embolism
I - infection –> UTI, pneumonia
R - retention –> urinary or faecal
I - intracranial pathology
U - uremia
M - metabolic –> hypoglycaemia, hypothyroidism, adrenal pathologies, Cushing’s disease
Identify which investigations may be appropriate as part of the “delirium screen.”
✔️ urine dipstick and MCS ✔️ urine toxicology / drug screen ✔️ FBC and WCC ✔️ inflammatory markers ✔️ UECs ✔️ CMP ✔️ eLFTs ✔️ fasting lipds ✔️ blood glucose level ✔️ iron and B12 + folate studies ✔️ syphilis and HIV serology ✔️ CT head (non-contrast) ✔️ CXR to exclude respiratory pathology for delirium
