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Phase 2 5. People and Illness > Dementia and delirium > Flashcards

Dementia and delirium Flashcards

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1
Q

What is cognition?

A
  • Attention/orientation
  • Memory
  • Executive functioning
  • Language
  • Calculation
  • Praxis
  • Visuospatial ability
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2
Q

What are the different types of attention?

A
  • Arousal
  • Sustained attention
  • Divided attention
  • Selective attention
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3
Q

What part of the brain is involved in attention?

A
  • Attentional function is distributed
  • Reticular activating system (RAS)
  • Cortical association areas
  • Multiple neurotransmitter systems involved
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4
Q

What are abnormalities in attention a hallmark of?

A

Delirium

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5
Q

How are deficits in attention tested?

A
  • Observe the patient
  • Specific tests:
  • Orientation in time and place (also depends on episodic memory)
  • Digit span-forward/backward (also depends on working memory)
  • Reciting months of the year (or days of the week) backwards
  • Serial 7s
  • Spell WORLD backwards
  • The STROOP Test
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6
Q

What is the stroop test?

A

Colours are spelt out on paper in a different coloured ink.

Patient is asked to say the colour the word is written in rather than the colour the word spells.

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7
Q

What is retrograde amnesia?

A

Amnesia of memories prior to the disease or injury

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8
Q

What is anterograde amnesia?

A

Amnesia of memories after the disease of injury

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9
Q

What functions does the frontal lobe have?

A
  • goal setting and motivation
  • judgement control of inhibition
  • flexibility and problem solving
  • planning/sequencing organisation
  • abstract reasoning
  • social behaviour personality
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10
Q

Where is the language centre in the brain?

A

Left hemisphere (in most people)

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11
Q

What are common disorders of the language centre?

A
  • aphasia
  • agraphia
  • alexia
  • nominal dysphasia
  • wernicke’s aphasia
  • Broca’s aphasia
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12
Q

Aphasia:

A

an impairment of language, affecting the production or comprehension of speech and the ability to read or write

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13
Q

Agraphia:

A

an acquired neurological disorder causing a loss in the ability to communicate through writing, either due to some form of motor dysfunction or an inability to spell

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14
Q

Alexia:

A

loss of the ability to read due to cerebral disorder

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15
Q

Describe Wernicke’s aphasia

A
  • Fluent
  • Phonemic and semantic paraphasia
  • Comprehension impaired
  • Wernicke’s area (temporal lobe)
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16
Q

Describe Broca’s aphasia

A
  • Non-fluent
  • Agrammatic
  • Phonemic paraphasias common
  • Broca’s area (inferior frontal lobe)
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17
Q

Where is the calculation centre of the brain?

A

The angular gyrus in the parietal lobe is crucial and the left hemisphere is generally important

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18
Q

acalculia:

A
  • inability to comprehend or write numbers properly
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19
Q

Anarithmetria:

A

difficulty with arithmetic

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20
Q

Dyspraxia:

A

Disorder causing difficulty in activities requiring coordination and movement

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21
Q

Which area of the brain is important for coordination and movement?

A

usually left hemisphere function - parietal and fontal lobe

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22
Q

How can deficits of praxis be classified?

A
  • Errors of :
  • Action conception (knowledge of actions/item function)
  • Action production (production/control of movement)
23
Q

How is apraxia/dyspraxia described?

A 
by region and description of the deficit
• Ideational apraxia
• Imitation of gestures
• Orobuccal movements
• Use of imagined objects
• Lower limb apraxia
24
Q

Where does the visual cortex feed into?

A

the parietal lobe and the temporal lobe

25
Q

What are common problems associated with visuospatial deficits?

A
  • Topographical disorientation
  • Difficulties with dressing (dressing apraxia)
  • Mis-reaching for objects
  • Visual neglect
  • Visual object agnosia
  • Prosopagnosia
26
Q

What is dressing apraxia

A

Inability to dress due to patient’s deficient knowledge of the spatial relations of his or her body

NB: although called apraxia - this is not to do with coordination of movement, but a visualspatial deficit!!

27
Q

Prosopagnosia

A

Disorder characterized by the inability to recognize faces

28
Q

How can constructural dyspraxia be tested in the clinical setting?

A

Part of the mini mental state exam - ask a patient to copy either a 3D cube or two pentagons overlapping

29
Q

What is dementia?

A

Syndrome with chronic, progressive (usually irreversible) cognitive
impairment due to brain disease

30
Q

What are the general clinical features?

A
  • Deterioration from higher level of function
  • Multiple cognitive deficits
  • Chronic duration > 6 months
  • Impact on social/occupational function
  • Personality change/disintegration
  • Decline in emotional control/motivation
  • No clouding of consciousness (exclude delirium)
31
Q

Describe the spectrum of cognitive impairment

A

Age related decline > Mild cognitive impairment (MCI) > dementia

32
Q

Describe the epidemiology of Dementia

A

65+ population prevalence of dementia is 7.1%
Equals one in every 79 (1.3%) of entire UK population
• 1 in every 14 of the population aged 65 years and over
850,000 people with dementia in 2015
40,000 people have early-onset dementia

33
Q

What is the cost of dementia on society?

A

• Total cost to society £26.3 billion

34
Q

List some causes of degenerative dementia

A
  • alzeimers disease
  • vascular dementia
  • fronto-temporal dementia
  • parkinson’s disease
  • huntington’s disease
  • wilson’s disease
  • MS
  • PSP
35
Q

List some causes of intracranial dementia

A
  • tumour
  • head injury
  • SDH
  • CVA
  • NPH
36
Q

List some causes of infections that cause dementia

A
  • CJD (prion disease)
  • neurosyphilis
  • HIV associated dementia
  • TB
37
Q

List some endocrine causes of dementia

A
  • hypothyroidism
  • hyperparathyroidism
  • cushing’s
  • addisons
38
Q

List some metabolic causes of dementia

A
  • uraemia
  • hepatic encephalopathy
  • hypoglycaemia
  • hypo/hypercalcaemia
  • hyper/hypomagnesiamia
39
Q

list the vitamin deficiencies that can cause dementia

A
  • B12
  • Folate
  • Thiamine
  • Niacin
40
Q

List the toxins that can cause dementia

A
  • Alcohol

- Lead

41
Q

What are the main psychiatric differentials of dementia

A
  • normal ageing
  • delirium
  • mild cognitive impairment
  • amnesiac syndromes
  • chronic brain damage (e.g. head injury or anoxia)
  • depression (pseudo-dementia)
  • Late onset schizophrenia or other psychosis
  • Learning disability
  • malingering presentations
  • dissociation
42
Q

How is dementia diagnosed?

A
  • Clinical assessment
  • Corroborative history
  • General physical examination
  • Mental State Examination
  • Standard (+/- specialised) bloods
  • Structured cognitive testing
  • Structural (+/- functional) imaging
43
Q

What investigations are required before diagnosing dementia?

A
  • FBC
  • ESR, CRP
  • Glucose
  • U+E
  • LFTs
  • Bone profile
  • TFTs
  • Urinalysis, MSSU
  • B12, folate
  • Consider HIV and syphilis serology
  • CXR
  • LP
  • ECG
  • CT/MRI
  • SPECT (includes dopamine FP-CIT)
  • EEG
44
Q

What tests can be performed to test cognition?

A
  • Addenbrooke’s Cognitive Examination (ACE)

* MMSE (Mini-Mental State Examination)

45
Q

Describe Addenbrooke’s Cognitive Examination (ACE)

A
  • 100 point test
  • More sensitive than MMSE in early disease
  • Covers executive function
  • More detailed, broader assessment of cognition than MMSE
  • More time consuming to administer
  • Two cut off scores 88 and 82
46
Q

Describe the MMSE (Mini-Mental State Examination)

A
  • Ease and speed of administration
  • High inter-rater reliability
  • Insensitive to early impairments eg mild cognitive impairment (MCI)
  • Poorly covers executive function. Weighted heavily towards memory/attention.
  • Influenced by age, education, socio-economic status
  • Screening tool and good for monitoring change
47
Q

What causes of dementia are reversible?

A
  • B12, folate deficiency
  • Hypothyroidism
  • Hydrocephalus, subdural haematoma, CNS tumour
  • Wilson’s disease
  • Cerebral vasculitis
  • Depression ‘pseudo-dementia’
  • Whipple’s disease
  • Metabolic problems
48
Q

What are the hallmark features of delirium?

A
  • Impaired consciousness
  • Hyperactive or hypoactive sub-type
  • Acute onset
  • Change in cognition
  • Cognitive deficits
  • Visual hallucinations (and other psychotic symptoms)
  • Sleep-wake cycle disruption
  • Affect changes
  • In most cases, evidence of an underlying direct cause
49
Q

What is delirium?

A

Acute neuropsychiatric syndrome

50
Q

What is the importance of delirium?

A

• 15-30% of hospital inpatients aged over 65
•At least 10% of unselected UK admissions in general
hospital
• 15% of older adults develop delirium during
inpatient stay
•Under-recognised in 2/3 of cases
•A wide range of complications – prevention is key

51
Q

Give a simplistic overview of the aetiology of delirium

A

predisposing factors + precipitating factors = delirium

52
Q

Give examples of precipitating factors that can result in delerium?

A
  • Infection
  • Stroke
  • Drugs
  • MI
  • Fractures
  • Cancer
  • Electrolyte /fluid balance problems
  • Heart failure
  • Diabetes
  • PVD
  • Alcohol withdrawal
53
Q

What are the non-pharmacological approaches to delirium

A

• Noise control and lighting
• Orientating influences – calendars, clocks, familiar objects, family (reality
orientation)
• Fluid balance/diet/bowel habit/pain control
• Regular communication/reassurance from staff. Address sensory impairment
• Limit variation in staff
• Encourage normal sleep cycle and side room if possible
• Early mobilising
• Avoid ward transfers
• Consider necessity of certain procedures
• Recognise frailty

54
Q

What are the pharmacological treatments used in delirium?

A

Antipsychotics:

  • haloperidol
  • olanzapine
  • risperidone
  • aripiprazole
  • quetiapine

Benzodiazepines:

  • lorazepam
  • diazepam

Others:

  • melatonin
  • trazodone
  • specific treatment of underlying cause

Phase 2 5. People and Illness (21 decks)

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