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OPIC > Dementia and delirium > Flashcards

Dementia and delirium Flashcards

1
Q

What are the causes of delirium?

A

THINK DELIRIUM
Trauma - head injury, subdural
Hypoxia eg. PE, MI, COPD, pneumonia
Increasing age and frality
Neck of femur fracture
smoKer
Drugs and alc - anti cholingergics, opiates, anti convulsants, recreatoinal
Environment
Lack of sleep
Imbalanced electrolytes
Retention
Infection/sepsis
Uncontrolled pain
Med conditions eg. dementia, IPD

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2
Q

What are the different types of delirium?

A

Hypoactive - apathy and quiet confusion, lethargic and w/drawn, can be confused w depression
Hyperactive - agitation, delusions and hallucinations, wandering and restlessness, disorientation, can be confused w schizophrenia
Mixed subtype - pt varies from hypoactive to hyperactive

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3
Q

What are the clinical features of delirium?

A
  • Reversed sleep wake cycle eg. sleeping in the day
  • Acute presentation w fluctuating course
  • Poor conc and inattentive
  • Short term mem loss
  • Agitated or emotionally unstable w exaggerated responses (labile mood changes)
  • Hallucinations and delusions
  • Unsteady gait and tremor
  • Poor language and speech
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4
Q

What criteria are used in the diagnosis of delirium?

A
  • DSM-5 criteria:
    Disturbance in awareness, acute onset, disturb cognition, no other neurocog disorder, evidence of an organic cause
  • Confusion Assessment Method - CAM - confusion suddenly and fluctuates w inattention, disorganised thinking, alt level of conc
  • 4AT - Alert, Attention, Acute change, Age, DOB place and current year
  • Abbreviated mental test- AMT
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5
Q

Delirium vs dementia

A

Delirium - acute, fluctuating course, inattentive, reversible, abnormal sleep wake cycle
Dementia - chronic presentation w progressive worsening, irreversible, attention normally intact

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6
Q

What are the ix into delirium?

A

Part of a confusion screen to understand the cause:
- Bedside - obs, ECG, cultures, BM, urine dips
- Bloods - FBC, U&Es, LFTs, Bone profile, Ca, HbA1c, VitB12, TFTs, CRP, toxicology, syphilis, eGFR
- Imaging - CXR, CT head, echo

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7
Q

What is the management of delirium?

A
  • May need to use the MCA as pt lack capacity
  • Treat underlying cause
  • Deescalation methods - change environments, reminders of what time it is and where they are, relaxation, familiar objects, address cause of behaviour, involved those close to pt
  • Meds - laxatives if cosntipated, remove anticholinergics, fluids, paracetamol
  • Rapid tranquillisation - if still harm to themselves or others despite deescalation methods this may be needed
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8
Q

What is cognitive impairment?

A
  • Disturb of higher cortical func inc mem, thinking, judgement
  • Not a specific illness but description of someone’s condition eg. dementia and delirium
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9
Q

What are the medications used in rapid tranquillisation?

A
  • Rapid tranquillisation can worsen delirium so careful consideration is required
  • Benzos eg. lorazepam - if from alcohol w/drawal = delirium tremens
  • Anti psychotics - haloperidol, olanzepine - beneficial effects in selected pt, those who are aggressive and don’t respond to de escalation, weakest dose possible and titrate to manage sx
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10
Q

What is the MCA?

A

Mental Capacity Act - a way to protect pt and act in their best interest once they have lost capacity. Involve next of kin where possible. Will use it to apply for Deprivation of Liberty Safeguarding.

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11
Q

What is involved in assessing capacity?

A

If they can’t:
- understand info relevant to decision
- retain info long enough to make a decision
- use info to make a decision
- communication decision
a pt is described as lacking capacity.

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12
Q

What are some differentials for delirium?

A
  • Dementia eg. Lewy body has fluctuating course
  • Depression and bipolar disorder, schizophrenia
  • Thyroid disease
  • Non convulsive epilepsy
  • Charles Bonnet syndrome
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13
Q

What is the difference between the Mental Health Act and the Mental Capacity Act?

A

Mental health act - applies if you have a mental illness, sets out rights it you are sectioned, only applied to treatment for mental health problems
Mental capacity act - if you do not have mental capacity to make certain decisions, decisions follow the best interests checklist, can have DoLS but not sectioned, can be applied to any treatments

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14
Q

What is delirium tremens?

A

Rapid onset of confusion precipitated by alcohol w/drawal.
Develops 72 hours after ceasing alcohol intake - sx peak on day 4-5.
CF - confusion, hallucinations, formication, sweating, HTN, seizures

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15
Q

What is formication?

A

Sensation of crawling insects on and under the skin

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16
Q

What is the management of delirium tremens?

A
  • Chlordiazepoxide - benzo
  • Fluids
  • Anti emetics
  • Pabrinex
  • Refer to local drug and alc liasion teams
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17
Q

What drugs often cause delirium?

A
  • Antidepressants
  • Anti cholinergics
  • Anti histamines
  • Benzos and mophine
  • Anticonvulsants
  • Anti Parkinsonism meds
  • Steroids
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18
Q

Dementia vs mild cog impairment vs normal ageing

A
  • Normal ageing - not remembering name of acquaintance and details of convo a year ago, occasionally forgetting things, occasionally having difficulty finding words but families not worried
  • Mild cognitive impairment - memory probs more than expected for age but not significantly impacting daily functioning
  • Dementia - more regular and more pronounced sx, must have impairment of ADLs
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19
Q

What is the difference between normal onset dementia and early onset dementia?

A

Causes - Alz, FTD and vascular in younger pt, Lewy body, Alz, vascular in older pt
Course - weeks to years in younger pt but years in older pt
Sx - memory loss less common in younger = lang and behavioural sx, changes personality

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20
Q

What are the causes/types of dementia?

A
  • Neurodegenerative - AD, vascular, FTD, IPD, Lewy body
  • Infective - HIV, Herpes simplex, syphilis
  • Prion - CJD, Kuru
  • Inflam - vasculopathies, sarcoid, autoimmune
  • Metabolic - poorly controlled endocrine disease, vit def
  • Genetic causes eg. MHD, Downs syndrome
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21
Q

What should you ask in dementia hx?

A
  • Timeline
  • Sx - memory, lang, vision, motor, continence, falls, hallucinations, personality, impulsivitiy, social func, sleep, appetite
  • Other causes - PMH, meds, substance use ever and now, depression, PTSD, menopause, vit def, polypharmacy, pain
  • FH
  • Beginning of the day to the end of the day - ADLs, sleeping, food
  • Important to try and get a collateral hx
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22
Q

What does MEMORY LANES stand for?

A

Memory
Employment
Motor sx
Overeating
Risk - driving, wandering, cooking, impulsivity and disinhib
Usual self - personality/social etiquette
Lang
Accidents - continence
Night
Exclude other illness
Sight

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23
Q

What is the examination of a dementia pt?

A
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24
Q

What cognitive assessments are used in dementia?

A
  • GPCOG
  • MMSE
  • MOCA
  • ACE-III
  • etc etc
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25
Q

What are the risks you need to assess in a pt w dementia?

A
  • Self harm, suicide
  • Aggression towaards others
  • Wandering and getting lost
  • Neglect
  • Med compliance
  • Meal prep - probs w gas and fire etc
  • Driving
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26
Q

What are the ix into dementia?

A
  • Baseline bloods - FBC, ESR, U+E, bone profile, HbA1c, LFT, TFT, serum B12 and folate levels
  • Neuro radiology - MRI - structural and functional
  • Neuropsychology
  • OT functional assessment
  • SALT
  • ECG
  • Virology eg. HIV and syphilis testing
  • CXR
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27
Q

What is the management of dementia?

A
  • Explain diagnosis and prognosis
  • MDT referral if need aftercare, safeguarding, support
  • Cholinesterase inhib Alzheimer’s
  • Memantine in Alz
  • Rivastigmine in IPD
  • Antipsychotics/antidepressants for BPSD
  • Support groups
  • Must inform DVLA for driving
28
Q

What is post cortical atrophy?

A
  • Problems w visual recognition - cortical blindness
  • Judging distances and coordination
  • Anxiety - insight that something is wrong
  • Visual problems despite normal visual exam

Management - same as Alzheimers

29
Q

What are the CFs of behavioural variant FTD?

A
  • 45-65 years
  • Lang and behavioural sx early on
  • Later movement and mem affected
  • Loss of empathy, apathy, disinhib, poor judgement, overeating/hyperorality, deterioration in planning and organising
  • Compulsive behaviour - cleaning, checking, hoarding
  • Misdiagnosed as a type of depression
30
Q

What is the management of bvFTD?

A
  • Explain diagnosis and prognosis
  • Supervision eg. can’t drive or work, avoid bad behaviour
  • No meds indicated, can make worse
  • MDT approach
  • Support for carers
31
Q

What is normal pressure hydrocephalus?

A

Excess cerebrospinal fluid accumulates in brains ventricles:
- Mild dementia - ADLs reduced, forgetfulness, short term mem loss
- Slow thought processes, apathy, impaired planning, reduced conc
- Loss of bladder continence, later on
- Difficulty walking - body bent forward, legs held wide apart - like walking on a boat
- WET WOBBLY AND WEIRD

32
Q

What are some red flags of normal pressure hydrocephalus?

A
  • Triad = urinary incontinence, dementia and gait abnormality
  • Rapid onset
  • <50yo
  • Recent head trauma
  • Associated sx - weight loss, headaches, seizures, raised ICP signs
  • Positive FH
  • WET WOBBLY AND WEIRD
33
Q

What is Alzheimer’s disease?

A

50-75% of all dementias. Progressive neurodegen disorder that causes deterioration in mental performance.
- Senile plaques
- Neurofibrillary tangles = tau proteins

34
Q

What are the CF of Alzheimer’s?

A
  • Cognitive impairment - poor mem, disorientated, lang problems
  • BPSD - agitation, depression, sleep cycle disturb, motor disturb
  • Reduced ability of ADL
  • Early impairment of memory is disease specific
35
Q

What is BPSD? What are the different types?

A

Behavioural and psychological sx of dementia.
1. Affective - agitation, depression, hoarding, screaming/crying
2. Apathetic - indifference, reduced motivation
3. Psychotic - delusions, hallucinations
4. Hyperactive - aggressive, irritable, lability ,resisting care, wandering, disinhibited

36
Q

What are some of the RF of Alzheimer’s?

A
  • Increasing age
  • Genetics - inherited causes are suggested by early onset disease
  • CVS disease
  • Depression
  • Low education attainment and low social engagement and support
  • Learning disabilities - get early onset
37
Q

What pharmacological therapy can you use for Alzheimer’s disease?

A
  • Mild to mod - acetylecholinesterase inhib eg. donepezil, rivastigmine = small improvements in cognition, ADLs and neuropsych sx
  • Mod to severe - NMDA receptor antagonist eg. memantine = reduces functional decline
37
Q

What pharmacological therapy can you use for Alzheimer’s disease?

A
  • Mild to mod - acetylecholinesterase inhib eg. donepezil, rivastigmine = small improvements in cognition, ADLs and neuropsych sx
  • Mod to severe - NMDA receptor antagonist eg. memantine = reduces functional decline
38
Q

What are the different types of vascular dementia?

A
  • Subcortical VD - dementia caused by small vessels of brain affected
  • Stroke related VD - 20% of pt w stroke develop this w/i 6 months
  • Single/multi infarct VD - collective burden of cerebrovascular disease from multiple strokes = dementia
  • Mixed dementia - VD and AD most commonly
39
Q

What is CADASIL? What are the characteristics?

A

Cerebral autosomal dominant arteriopathy w subcortical infarcts and leukoencephalopathy.
- Recurrent migraine type headaches
- Multiple strokes ~50 yos
- Progressive dementia

40
Q

What are the CFs of VD?

A

Stepwise (disease specific) cognitive decline w or w/o a stroke. Sx stay the same for a while and suddenly get worse.
- Predominant gait abnormalities
- Attention deficits
- Personality changes
- Focal neurological signs due to previous stroke
- Other dementia sx - cognitive impairment, BPSD, reduced ADLs

41
Q

What is the management of VD?

A
  • VD is preventable - reduce CVS RF and RF of stroke
  • Acetylcholinesterase inhibs and NMDA receptor antagonists have limited efficacy in VD
  • Other general management - advance care planning, stop driving, manage BPSD, care plans and end of life care
42
Q

Dementia w Lewy body vs Parkinson’s disease

A

Parkinson’s disease dementia - have IPD for more than a year before the onset of dementia
Dementia w Lewy body - developing dementia w/i one year of Parkinsonism features

43
Q

What are the CF of dementia w Lewy body?

A
  • Fluctuating cognition - variations in attention and alertness
  • Visual hallucinations - well formed and detailed
  • Parkinsonism - tremor, rigidity, bradykinesia, postural instability
  • REM sleep disorders - can precede cognitive decline
  • Hypersomnia - excess daytime sleepiness
  • Hyposmia - decreased sense of smell
  • Severe autonomic dysfunc - constipation, orthostatic hypotension, urinary incontinence
  • Cognitive impairment, BPSD, reduced ADLs
44
Q

What is the diagnostic criteria of DLB?

A
  • Probable DLB - >2 core CF or 1 core CF with >1 biomarker
  • Possible DLB - 1 core CF and no biomarker or just biomarkers
  • Less likely DLB - presence of another that could account for sx or parkinsonian features are the only core CF
45
Q

What is the management of DLB?

A
  • Cholinesterase inhib = first line treatment for DLB w troublesome cognitive/behavioural sx
  • Memantine has limited efficacy in DLB
  • Anti psychotics can worse sx in pt w DLB
  • Melatonin in REM sleep disorders
  • Levodopa
46
Q

What is frontotemporal dementia?

A

Focal degeneration of the frontal and temporal lobes characterised by predominant disturb in social behaviour, personality and language. Is very rare ~2% of dementias.

47
Q

What are the subtypes of FTD?

A
  • bvFTD - behavioural variant, progressive personality and behaviour change
  • Primary progressive aphasia - insidious onset of progressive lang defects, non fluent = articulatory difficulty or semantic PPA = impaired single word comprehension
48
Q

What are the signs of PPA?

A
  • Effortful speech
  • Halting speech
  • Speech sound errors
  • Speech apraxia
  • Word finding difficulty
  • Surface dyslexia and dysgraphia
49
Q

What are the motor syndromes of FTD?

A
  • FTD w MND
  • Cortico basal syndrome - asymmetrical akinesia, dystonia, apraxia, alien limb phenomenon
  • Progressive supranuclear palsy - difficulty looking up
50
Q

What are some neuroimaging?

A
  • bvFTD - frontal and temporal atrophy
  • Nonfluent PPA - early atrophy and hypoperfusion
  • Semantic PPA - significant ant temporal atrophy
51
Q

What is the management for FTD?

A

No specific treatments, mainly aimed at improving ADL:
- Financial advice
- Physical supervision
- Exercise encourage
- Mobility - PT and providing aids
- SALT
- Behavioural modification
- SSRIs and atypical anti psychotics

52
Q

What are some reversible causes of dementia?

A
  • Vit B12 def
  • Normal pressure hydrocephalus
  • Wernicke Korsakoff syndrome/alc related dementia
  • Hypothyroidism
  • Neurosyphilis and AIDs dementia
  • Space occupying lesion
53
Q

What is the treatment of normal pressure hydrocephalus?

A
  • Ventriculo peritoneal shunting
  • If not ft for surgery = repeated CSF taps
54
Q

What is CJD?

A

Creutzfeldt Jakob disease - rapidly progressive neurological condition, very very rare.
CFs - prion causes huge cell death in brain = memory and mood changes, speech and lang impairment, seizures and death

55
Q

What is Wenicke Korsakoff’s syndrome?

A
  • Wernicke’s encephalopathy = confusion, ataxia, ophthalmoplegia/nystagmus
  • Untreated Wenicke’s can progress to Korsakoff’s = profound anterograde amnesia w limited retrograde amnesia
  • Caused by chronic alcohol abuse and thiamine deficiency
56
Q

Retrograde vs anterograde amnesia?

A

Anterograde - impaired capacity for new learning
Retrograde - loss of info acquired before onset of amnesia

57
Q

What are some preventable causes of dementia?

A
  • Wernickes encephalopathy/Korsakoff’s syndrome
  • Vascular dementia
  • Neurosyphilis
  • HIV associated dementia
58
Q

What are the CT changes in Alz?

A

Cortical atrophy in limbic system, hippocampus and temporal and parietal lobes

59
Q

When are anti psychotics used in dementia? Give some examples

A

To treat pt w BPSD - aggressive, disruptive, delusions, hallucinations.
- Risperidone - up to 6 weeks for persistent aggression when there is risk of harm to pt or others
- Haloperidol but SEs for people in dementia normally deemed too severe to use, emergency

60
Q

What is the problem w anti psychotics in dementia?

A
  • Should never be the first choice of treatment
  • Anti psychotics seem to not reduce disruptive behaviour
  • Serious SEs
  • Other interventions work better - see if a common condition is causing behaviour and treat, med review, behaviour specialist
61
Q

What are the SEs of antipsychotics in dementia?

A
  • Drowsiness, confusion and increased falls
  • Shaking/tremors and decreased mobility
  • Increased risk infection - chest and UTI
  • Stroke and VTE
  • Weight gain and diabetes
  • Death
  • Worsen cognition
62
Q

When should you consider antipsychotic drugs in dementia?

A
  • Other steps have failed
  • Person is severely distressed
  • Person could hurt them self or others
  • Always start at the lowest possible dose and carefully monitor pt to see if sx improve
  • Always stop meds when its no longer needed
63
Q

What symptoms do antipsychotics not help with?

A
  • Distress and anxiety during personal care
  • Repetitive vocalisations
  • Walking about
  • Social w/drawal
  • Changes in levels of inhibition
64
Q

What are the problems w tranquilisation?

A
  • Falls - if sedated but not sleeping
  • Respiratory depression if using lorazepam
  • Haloperidol can worsen Parkinson’s symptoms or cause

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