Dementia and Delirium Flashcards
1
Q
Early stage features of dementia
A
- Poor memory esp Alzheimers
- Subtle changes mood and behaviour
- Minimal intrusion into day to day if these are not too demanding
2
Q
Mild stage features of dementia
A
- Memory problems more prominent - eg word finding problems
- Changes in behaviour marked
- Disability apparent - instrumental ADLs eg finance difficult (self care ok)
- Frequent support
- Awareness of disability diverges from reality
3
Q
Later stages dementia
A
- Severe memory problems - failure to recognise familiar people
- Changes in behaviour - marked
- Disability severe - basic aspects of personal functioning are failing, continious supervision
4
Q
Behavioural and psychological symptoms of dementia BPSD
A
- Non-cognitive symptoms of dementia
- Diverse - not just aggression, can be anxiety, low mood, hallucinations, sun-downing
- Prognostic indicator for admission to care home - challenging for patients and carers
5
Q
Clusters of BPSD - 4 main
A
- Affective - depression, anxiety, agitation
- Apathetic - loss of motivation, appetite and eating problems
- Psychotic - paranoid, delusions, hallucinations
- Hyperactive - wandering, agitiation
6
Q
BPSD management
A
- Investigate and treat precipitating factors - eg pain, unfamiliar environment
- Monitor with ABC chart (challenging behaviour chart)
- Non-pharm - behavioural management, music therapy
- Pharm - antipsychotic (caution with Lewy Body dementia - dopamine antagonists)
7
Q
Dementia subtypes comparison
A
- Ask about onset
- First symptoms
- Mood/behavioural problems
- Structural brain imaging changes - can be normal
8
Q
Define delirium
A
- Transiet and global impairment of cognition
- Disturbances of attention and conscious level
- Abnormal psychomotor behaviour
- Disturbed sleep-wake cycle
- Emotional disturbance
- Onset acute
- Symptoms fluctuate
- Can have hallucination (mostly visual) and delusions
9
Q
Frequent misdiagnoses of delirium
A
- Depression - hypoactive
- Dementia
- Manic disorder - hyperactive
10
Q
Risk factors for delirium
A
- Vision impairment
- Infection
- Aged >65 or 80
- Cognitive impairment
- Fracture on admission
11
Q
Causes of delirium
A
12
Q
Medications that can cause delirium
A
- Anti psychotic
- Anti-parkinsons
- Anticholinergics eg oxybutynin
- Opiates
- Steroids
- Diuretics
- Recreational drugs or alcohol
13
Q
Confusion assessment method
A
- Criteria to diagnose delirium 4 features:
- Acute onset and fluctuating
- Inattention
- Disorganised thinking
- Altered level of consciousness
14
Q
Delirium screening and assessment
A
- THINK DELIRIUM
- 4AT
15
Q
Immediate action when suspect delirium
A
16
Q
General management of delirium
A
- Manage underlying cause
- Reassure and re-orientate
- Optimise enviroment
- Manage distress
17
Q
Pharm management of delirum
A
- ONLY AS LAST RESORT
- Haloperidol
- Lorazepam
18
Q
Outcome of delirium
A
- Increased length of stay and complications eg falls/infection
- Readmission within 1 year
- Increased mortality at 1 year
- Insitutionalisation
19
Q
Delirium and persistent cognitive impairment
A
- Do not return back to baseline or takes a long time to get back to baseline
- Can take more than 3 months in some cases
- Can precipitate or worsen dementia
20
Q
Dementia
A
- Cognitive impairement
- Decline in both memory and thinking
- Sufficient to impair personal ADLs
- Problems with processing of incoming information and maintaining/directing attention
- Clear consciousness
- Above syndrome present for 6 months or more
21
Q
Stages of dementia occuring
A
Normal ageing
Mild cognitive impairment
Dementia
Not everyone with MCI will get dementia
22
Q
What is MCI?
A
- Memory, problem solving, planning, language and visuospatial awareness
- Does not interfere significantly with daily life
- 10-15% develop dementia
23
Q
What is memory clinic?
A
- MDT
- Aims for timely and early diagnosis
- Assess and diagnose dementia
- Psychosocial interventions for dementia
- Inc community mental health teams for older people
24
Q
Why do we have memory clinic and diagnose dementia?
A
- Relief gained
- Optimise medical management
- Maximise autonomy
- Access care and services
- Risk reduction
- Clinical and cost effectiveness
25
Assessment in GP for ?dementia
* GPCOG
* 6CIT
26
How are patients managed if rapidly progressive dementia?
* Refer to neurology
* Could be something underlying eg Creutzfelt Jakob
27
4 components of memory clinic
* History
* Mental state exam and physical exam
* Cognitive assessment
* Inv
28
Memory clinic history
* Specific examples of forgetfullness etc
* ODPARA
* Baseline function
* Behavioural and psychological symptoms - altered behaviour (eg agression), mood changes, hallucinations
* SH - management of ADLs, levels of social support
* RISKS
29
Risks in patients with dementia in memory clinic to assess
* Self neglect
* Wandering/getting lost
* Driving
* Vulnerability
* Agitation
* Unsafe use of appliances
* Carer strain
30
Key cognitive domains
- Executive function
- Memory
- Social cognition - social cues
- Language
- Complex attention - focus
- Perceptual motor control
31
Standardised assessment tools used in memory clinic
* MOCA
* ACE3
* 6-CIT
* AMTS
32
MOCA values
more 26 = normal
19-25 = mild
10-18 = moderate
less 10 - severe
33
Limitations of assessment of cognition - what can affect
* Insensitive to specific cognitive deficits
* Educational achievement and undiagnosed learning issues
* Sensory impairment
* English as second langiage
* Cultural
* Disabilities
* Enviroment
* Anxiety
34
What is MOCA
Out of 30
Takes 10 mins
Can be translated, braille
Need pen and paper
35
ACE III
* Gold standard
* 5 domains - attention, memory, verbal fluency, language
* Approx 20 mins
* Mini ACE is abbreviated - 30pts (whole one 100pts)
* Cut offs 88 or 82 or less
36
INV for confusion screen
* Bloods - FBC, U&E, TFT, LFT Glucose, B12 and folate, calcium
* ECG - for prescribing
* CT head/MRI brain (dementia subtype)
* Sometimes HIV/syphillis
37
Further specilaist inv
* FDG-PET - amyloid
* DAT Scan for ?Lewy body
* CSF analysis
38
Driving and dementia
* Must inform DVLA
* Fitness to drive depends on level of impairment (eg visuospatial), familiar drives, driving along, near misses/accidents
39
Drug treatments for dementia
* Vascular - no drugs, manage RF
* Drugs for alzheimers/lewy body
40
Anti-dementia medication examples
Acetylcholinesterase inhibitors -
* Donepezil, Rivastigmine, Galantamine
* Indicated in mild/moderate AD
NMDA antagonist
* Memantine
* Indicated in moderate/severe AD
41
Side effects of antidementia drugs - anticholin
* GI
* Reduced appetite
* Dizziness
* Agitation
* ECG NEEDED - check for bradycardia and PR interval
42
NMDA side effects
* Constipation
* Dizzy
* Drowsy
* Headaches
* eGFR - monitor and check function
43
Main causes of disability later in life
Dementia
44
What can cause dementia?
* Alzheimers
* Vascular
* Fronto-temporal
* Alcoholic
* Lewy body
45
