Dementia and delirium? Flashcards
What is dementia?
- A chronic, progressive syndrome of insidious onset
What are the cognitive symptoms of dementia?
- Impaired memory (temporal lobe involvement)
- Impaired orientation (temporal lobe involvement)
- Impaired learning capacity (temporal lobe involvement)
- Impaired judgement (frontal lobe involvement)
What are the non-cognitive symptoms of dementia?
- Behavioural symptoms
- Depression and anxiety
- Psychotic features
- Sleep symptoms
What are the behavioural symptoms of dementia?
- Agitation
- Aggression (frontal lobe involvement)
- Wandering
- Sexual disinhibition (frontal lobe involvement)
What are the psychotic features of dementia?
- Visual and auditory hallucinations
- Persecutory delusions
What are the sleep symptoms of dementia?
- Insomnia
- Daytime drowsiness (decreased cortical activity)
Before we can diagnose dementia what do we need to do?
- Exclude organic causes of cognitive decline
What are some other conditions that can present with features of dementia?
- Hypothyroidism
- Hypercalcaemia
- B12 deficiency
- Normal pressure hydrocephalus (abnormal gait, incontinence, confusion)
- Exclude delirium
What features do we need to look for when making a dementia diagnosis?
- Features of progressive decline
- Impairment of activities of daily living in a patient with a normal conscious level
What are the different types of dementia?
- Alzheimer’s disease
- Vascular dementia
- Dementia with Lewy bodies
- Frontotemporal dementia
What are the macroscopic features of Alzheimer’s disease?
- Global cortical atrophy
- Sulcal widening
- Enlarged ventricles (primarily lateral and third affected)
What are the microscopic features of Alzheimer’s disease?
- Plaques composed of amyloid beta
- Tangles of hyperphosphorylated tau
How do plaques and tangles affect neurones?
- Kill neurones
- Since neurogenesis is limited in the CNS, any neurones that die are unlikely to be replaced
Which neurones are predominantly affected by Alzheimer’s disease?
- Cholinergic neurones
- Noradrenergic
- Serotonergic
- Those expressing somatostatin
What causes vascular dementia?
- Cerebrovascular disease (multiple small strokes)
What are the risk factors for vascular dementia?
- Previous stroke/MI
- Hypertension
- Hypercholesterolaemia
- Diabetes
- Smoking
How does vascular dementia present?
- Stepwise, maybe with focal neurological features
What is dementia with Lewy bodies?
- Essentially the same disease as Parkinson’s
- But if dementia precedes movement disorder we call it dementia with Lewy bodies
What is the pathology of dementia with Lewy bodies?
- Aggregation of alpha synuclein
- Forms spherical intracytoplasmic inclusions
Where are the main deposits of intracytoplasmic inclusions found across the brain?
- Substantia nigra
- Temporal lobe
- Frontal lobe
- Cingulate gyrus
How does dementia with Lewy bodies present?
- Fluctuating cognition and alertness
- Vivid visual hallucinations
- Parkinsonian features (may cause repeated falls)
Why can we not give patients with dementia with Lewy bodies antipsychotics?
- Neuroleptic malignant syndrome, a psychiatric emergency
What are the symptoms of neuroleptic malignant syndrome?
- Fever
- Encephalopathy
- Vital signs instability (tachycardia, tachypnoea, fluctuating BP)
- Elevated creatine phosphokinase
- Rigidity
What is frontotemporal dementia?
- Second most common cause of early onset dementia
- Frontal and temporal lobe atrophy
What are the symptoms of frontotemporal dementia?
- Behavioural disinhibition
- Inappropriate social behaviour
- Loss of motivation without depression (caused by damage to anterior cingulate cortex)
- Repetitive/ritualistic behaviours
- Non fluent (Broca type) aphasia
What is the pathology of AIDS associated dementia?
- Entry of HIV infected macrophages into the brain is thought to lead to indirect damage to neurones
- Insidious onset but rapid progression once established
What are the clinical features of AIDs associated dementia?
- Cognitive impairment
- Psychomotor retardation (slow thoughts and movements)
- Tremor
- Ataxia
- Dysarthria
- Incontinence
How is dementia managed?
- Using the bio-psycho-social model
What is the biological aspect of dementia management?
- Drugs such as acetylcholinesterase inhibitors and NMDA antagonists
Give some examples of acetylcholinesterase inhibitors used to treat dementia?
- Donepezil
- Rivastigmine
- Galantamine
Give some examples of NMDA antagonists
- Memantine
- Useful for treating agitation
What is the social aspect of dementia management?
- Explain diagnosis sensitively
- Talk about problems that will arise and how they will be managed
- Give results of any special investigations
- Deal with the topics of driving and finances
- Day care and respite care
- Residential/nursing home placement
What is delirium?
- Sometimes called acute confusional state
- Often reversible, due to organic cause
- Associated with a variety of insults to the brain which may cause neuronal damage and inflammation
- Dementia can predispose to episodes of delirium
What are the features of delirium?
- Rapid onset of confusion
- Clouded consciousness
- Fluctuating course
- Maybe transient visual hallucinations
- Often exaggerated emotional responses (e.g. aggression)
What are the different types of delirium?
- Hypoactive
- Hyperactive
What are the features of hypoactive delirium?
- Withdrawn
- Quiet
- Sleepy
- More likely to be missed/confused with something else
What are the features of hyperactive delirium?
- Restless
- Agitated
- Aggressive
- Mood may rapidly fluctuate
- Persecutory delusions
- Symptoms worse at start and end of day
What are the causes of delirium?
- Nutritional
- Intracranial
- Extracranial infections
- Iatrogenic
- Alcohol
- Endocrine
- Metabolic
What are the nutritional causes of delirium?
- Vitamin deficiencies
What are the intracranial causes of delirium?
- Strokes
- TIAs
- Epilepsy
- Infection etc
What are the extracranial infectious causes of delirium?
- UTI
- Pneumonia
What are the alcohol-related causes of delirium?
- Intoxication
- Withdrawal (including delirium tremens)
What are the endocrine causes of delirium?
- Thyroid
- Pancreas
What are the metabolic causes of delirium?
- Hypoxia
- Renal
- Hepatic
What is the management of delirium?
- Find and treat the underlying cause
What is the prognosis of delirium?
- Increases risk of dementia
- Associated with mortality
- Patients have lengthy hospital stays and have a high risk of readmission
