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Physiotherapy Across Lifespan II > Dementia and Delirium > Flashcards

Dementia and Delirium Flashcards

1
Q

Dementia

A

Permanent impairment of intellectual capacity and personality integration, due to the loss of or damage to neurons in the brain.
cognitive impairment + functional disability

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2
Q

Delirium

A

Temporary cognitive impairment due to an acute illness

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3
Q

describe the epidemiology of dementia

A

total prevalence over 65 10.3 per 100
65-74 3 per 100
75-84 18.7 per 100
85 and above 47.2 per 100

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4
Q

how is the diagnosis of a patient’s cognitive function conducted

A

Patient history
Collateral history (essential)
Patient examination (incl. mental state examination)
Blood tests
Neuroimaging

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5
Q

how is the mini mental state exam conducted

A

orientation -
a(5) date/month/year/day/season
b(5) city/country/county/building/ floor
registration (3)- test their memory - name 3 objects e.g ball, car, man. repeat the objects repeat 6 times
attention (5)- from 100 subtract 7 5 times (93, 86, 79, 72, 65)
spell WORLD backwards
recall (3) - list the 3 words I said earlier
Language(2) - name these objects (pen, watch), repeat (1)”no ifs, ands, or buts”
Reading (1) - show card write CLOSE YOUR EYES. tell them to do what it says.
writing (1) - write a short sentence
three stage command (3) - take this paper in your left hand fold it in half and put it on the floor
construction (1) - copy this drawing
scored out of 30

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6
Q

what is neuropsychological testing

A

Used to test specific cognitive domains
Verbal memory, recent memory, remote memory
Orientation, language, motor skills, perception
executive function

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7
Q

how is diagnosing a dementia subtype conducted

A

History
Time course
Examination
Vascular or neurological signs
Blood tests
Glucose / B12 / Folic acid / TFT’s / Syphilis
Blood tests usually normal though
Imaging
CT / MRI / SPECT/PET
Lumbar puncture for CSF amyloid and tau measurement

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8
Q

how is the structural integrity of the cerebrum assessed and what is its purpose in diagnosis of dementia

A

purpose -To exclude structural causes of dementia
To assess degree of grey and white ischaemia
Brain tumours, Normal Pressure Hydrocephalus
To assess degree and distribution of atrophy

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9
Q

what is the purpose of of conducting a SPECT/PET for dementia

A

To assess hypoperfusion in brain regions

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10
Q

what patients are typically indications for scanning to assess dementia

A

Recent onset of cognitive impairment
< 2 years

Atypical history for AD
Rapid deterioration over weeks
Unexplained neurological symptoms or signs
Known cancer
Gait balance problems/ incontinence early in course of dementia

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11
Q

what neuroimaging is available for the diagnosis of dementia

A

CT Brain (widely available)
MRI Brain (fairly available)
PET scan brain (pretty unavailable)
SPECT scan brain (rarely done anymore)

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12
Q

list the dementia subtype

A

alzheimer’s disease - 50%
vascular dementia - 15%
‘Mixed’ dementia - 15%
Dementia with Lewy bodies - 10%
Frontotemporal dementia - 8%
Other -2%

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13
Q

describe mild cognitive impairment

A

a subtype of cognitive impairmentAbnormal tests but normal function

Amnestic / non amnestic
Single domain / multi-domain

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14
Q

what is the expected clinical presentation of a patient with dementia

A

abnormal tests and abnormal function
Performance must be below 5th centile in 2 or more cognitive domains
Functional disability must be as a result of cognitive impairment

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15
Q

describe the early investigation conducted for dementia

A

initial assessment - basic cognitive assessment e.g. mini mental state exam, check for function impairment e.g. paying bills, shopping, check for mood disorder e.g. anger, depression
neurogimaging - CT, MRI, PET, SPECT
Indications for neuroimaging - short duration of symptoms (<2 yrs), unexplained CNS symptoms (headaches, seizures), unexplained CNS signs (hemiparesis), cancer hx
neuropsychological testing - for MMSE >24
Common differential diagnosis - mild cognitive impairments, early dementia

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16
Q

describe the classification of AD (Alzheimer’s Disease

A

Very mild AD = MMSE > 24
Mild AD = MMSE 20-23
Moderate AD = MMSE 16-19
Severe MMSE < 15

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17
Q

What is the management strategy for very mild AD (Alzheimer’s Disease)

A

establish diagnosis
consider enduring power of attorney
consider driving assessment
consider a cholinesterase inhibitor if function impaired

18
Q

What is the management strategy for mild AD (Alzheimer’s Disease)

A

establish diagnosis
consider enduring power of attorney
consider driving assessment
consider a cholinesterase inhibitor if function impaired

19
Q

What is the management strategy for moderate AD (Alzheimer’s Disease)

A

establish diagnosis
consider enduring power of attorney
consider cognitive enhancer/combination therapy of memantine with cholinesterase inhibitor
check for behaviour disturbances and treat
check for carer stress

20
Q

What is the management strategy for severe AD (Alzheimer’s Disease)

A

consider cognitive enhancer
consider for behavioural and psychological symptoms of dementia
consider social support for carer stress

21
Q

what drugs should be avoided for alzheimer’s disease

A

opioids
drugs with anticholinergic action
benzodiasepines

22
Q

what sedatives are typically given for behavioural and psychological symptoms of dementia (BPSD)

A

trazodone
quetiapine
haloperidol
lorazepam

23
Q

what non pharmacological intervention is available for BPSD (behavioural and psychological symptoms of dementia)

A

Behaviour management
avoid overstimulation
music therapy
staff training

24
Q

what assessment is conducted for AD in the nursing home

A

assess personal ADL, e.g. toileting, dressing, mobility
assess appetite, nutritional state and food refusal
assess for anxiety and depression and BPSD
Initiate palliative care planning and discuss resuscitation status

25
Q

describe the non pharmacological intervention of AD in nursing home

A

BPSD. - simple environmental and psychological intervention
environment should be non-stressful, constant, and familiar e.g. include personal belongings

26
Q

3 types of cholinesterase inhibitors

A

Donepezil
Rivastigmine
Galantamine

27
Q

how successful is cholinesterase inhibitors

A

1/3 improve symptomatically on these medications but disease progression continues unabated

28
Q

list name and purpose of glutamate receptor antagonists

A

Ebixa
Reduces background “noise” in brain
Reduces caregiver time in moderate to severe dementia

29
Q

management of complications associated with dementia

A

Wandering - Avoid drugs / restraints
Depression - Antidepressants
Psychosis - Antipsychotics
Aggression - Antipsychotics / sedatives

30
Q

how is delirium diagnosed

A

DSM - IV
Disturbance of consciousness
Reduced attention
Change in cognition not better accounted for by dementia
Sundowning / fluctuation
Recent onset (hours to days) with fluctuation
Evidence of a general medical condition as underlying cause

31
Q

What is delirium

A

Temporary cognitive impairment due to an acute illness
Acute confusional state
An acute disorder of attention and cognition

32
Q

describe the prevalence of delirium

A

community dwellers above 55 - 1.1%
community dwellers above 85 - 13.6%
acute inpatients between 60-97 - 22%
emergency room patient above 70 - 40%

33
Q

list the risk factors of delirium

A

Advanced age
Pre-existing cognitive impairment
Depression
Alcoholism
co-morbid conditions
previous delirium
medication
surgery

34
Q

perioperative delirium is associated with

A

Age
Pre-existing cognitive impairment
Anticholinergic drugs

35
Q

causes delirium

A

Acute illness
Infections most common cause
UTI / RTI / urinary retention occasionally
Cardiopulmonary problems
CCF, silent MI’s etc
Malnutrition (thiamine deficiency)
Cancer
Constipation
CNS causes rare
Stroke (CVA), Sub-dural haematoma, Epilepsy
medication - psychotrophic

36
Q

describe the presentations of delirium

A

Cognitive decrement
Relatively abrupt onset (hours to days)
Level of consciousness reduced
Reduced attention & concentration
Activated (1/3 - 1/2) and hypoactive (1/2 - 2/3) states
Mood changes
Illusions and visual hallucinations

37
Q

what clinical assessments are conducted to diagnose delirium

A

High index of suspicion
Collateral history
Mental testing
Check medications
Physical exam including a rectal exam
Basic blood tests / urinalysis / drug levels
ECG / CXR

38
Q

what tools are available to detect delirium

A

Confusion Assessment Method -9 questions looking for 4 features associated with delirium
Acute onset /fluctuating course
Inattention
Disorganised thinking
Altered level of consciousness
delirium rating scale
DSM IV - Gold standard
4AT

39
Q

Management of delirium

A

Adequate food and fluid
Maintain a balance between under and over stimulation
Minimize disorientation
Avoid iatrogenic complications
Treat underlying cause
Antibiotics/ fluids / enemas etc

Specific delirium treatments
Poorly studied
Neuroleptics and benzodiazepines sometimes used in activated states
ECT (Nordic countries)

40
Q

how can delirium be prevented

A

Cognitive impairment
Sleep deprivation
Immobility
Visual impairment
Hearing impairment
Dehydration

41
Q

what are the possible outcomes of delirium

A

high morbidity
high mortality

Physiotherapy Across Lifespan II (8 decks)

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