Dementia and delirium Flashcards
What is cognition?
- Attention/orientation
- Memory
- Executive functioning
- Language
- Calculation
- Praxis
- Visuospatial ability
What are the different types of attention?
- Arousal
- Sustained attention
- Divided attention
- Selective attention
What part of the brain is involved in attention?
- Attentional function is distributed
- Reticular activating system (RAS)
- Cortical association areas
- Multiple neurotransmitter systems involved
What are abnormalities in attention a hallmark of?
Delirium
How are deficits in attention tested?
- 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
What is the stroop test?
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.
What is retrograde amnesia?
Amnesia of memories prior to the disease or injury
What is anterograde amnesia?
Amnesia of memories after the disease of injury
What functions does the frontal lobe have?
- goal setting and motivation
- judgement control of inhibition
- flexibility and problem solving
- planning/sequencing organisation
- abstract reasoning
- social behaviour personality
Where is the language centre in the brain?
Left hemisphere (in most people)
What are common disorders of the language centre?
- aphasia
- agraphia
- alexia
- nominal dysphasia
- wernicke’s aphasia
- Broca’s aphasia
Aphasia:
an impairment of language, affecting the production or comprehension of speech and the ability to read or write
Agraphia:
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
Alexia:
loss of the ability to read due to cerebral disorder
Describe Wernicke’s aphasia
- Fluent
- Phonemic and semantic paraphasia
- Comprehension impaired
- Wernicke’s area (temporal lobe)
Describe Broca’s aphasia
- Non-fluent
- Agrammatic
- Phonemic paraphasias common
- Broca’s area (inferior frontal lobe)
Where is the calculation centre of the brain?
The angular gyrus in the parietal lobe is crucial and the left hemisphere is generally important
acalculia:
- inability to comprehend or write numbers properly
Anarithmetria:
difficulty with arithmetic
Dyspraxia:
Disorder causing difficulty in activities requiring coordination and movement
Which area of the brain is important for coordination and movement?
usually left hemisphere function - parietal and fontal lobe
How can deficits of praxis be classified?
- Errors of :
- Action conception (knowledge of actions/item function)
- Action production (production/control of movement)
How is apraxia/dyspraxia described?
by region and description of the deficit • Ideational apraxia • Imitation of gestures • Orobuccal movements • Use of imagined objects • Lower limb apraxia
Where does the visual cortex feed into?
the parietal lobe and the temporal lobe
What are common problems associated with visuospatial deficits?
- Topographical disorientation
- Difficulties with dressing (dressing apraxia)
- Mis-reaching for objects
- Visual neglect
- Visual object agnosia
- Prosopagnosia
What is dressing apraxia
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!!
Prosopagnosia
Disorder characterized by the inability to recognize faces
How can constructural dyspraxia be tested in the clinical setting?
Part of the mini mental state exam - ask a patient to copy either a 3D cube or two pentagons overlapping
What is dementia?
Syndrome with chronic, progressive (usually irreversible) cognitive
impairment due to brain disease
What are the general clinical features?
- 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)
Describe the spectrum of cognitive impairment
Age related decline > Mild cognitive impairment (MCI) > dementia
Describe the epidemiology of Dementia
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
What is the cost of dementia on society?
• Total cost to society £26.3 billion
List some causes of degenerative dementia
- alzeimers disease
- vascular dementia
- fronto-temporal dementia
- parkinson’s disease
- huntington’s disease
- wilson’s disease
- MS
- PSP
List some causes of intracranial dementia
- tumour
- head injury
- SDH
- CVA
- NPH
List some causes of infections that cause dementia
- CJD (prion disease)
- neurosyphilis
- HIV associated dementia
- TB
List some endocrine causes of dementia
- hypothyroidism
- hyperparathyroidism
- cushing’s
- addisons
List some metabolic causes of dementia
- uraemia
- hepatic encephalopathy
- hypoglycaemia
- hypo/hypercalcaemia
- hyper/hypomagnesiamia
list the vitamin deficiencies that can cause dementia
- B12
- Folate
- Thiamine
- Niacin
List the toxins that can cause dementia
- Alcohol
- Lead
What are the main psychiatric differentials of dementia
- 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
How is dementia diagnosed?
- Clinical assessment
- Corroborative history
- General physical examination
- Mental State Examination
- Standard (+/- specialised) bloods
- Structured cognitive testing
- Structural (+/- functional) imaging
What investigations are required before diagnosing dementia?
- 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
What tests can be performed to test cognition?
- Addenbrooke’s Cognitive Examination (ACE)
* MMSE (Mini-Mental State Examination)
Describe Addenbrooke’s Cognitive Examination (ACE)
- 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
Describe the MMSE (Mini-Mental State Examination)
- 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
What causes of dementia are reversible?
- B12, folate deficiency
- Hypothyroidism
- Hydrocephalus, subdural haematoma, CNS tumour
- Wilson’s disease
- Cerebral vasculitis
- Depression ‘pseudo-dementia’
- Whipple’s disease
- Metabolic problems
What are the hallmark features of delirium?
- 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
What is delirium?
Acute neuropsychiatric syndrome
What is the importance of delirium?
• 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
Give a simplistic overview of the aetiology of delirium
predisposing factors + precipitating factors = delirium
Give examples of precipitating factors that can result in delerium?
- Infection
- Stroke
- Drugs
- MI
- Fractures
- Cancer
- Electrolyte /fluid balance problems
- Heart failure
- Diabetes
- PVD
- Alcohol withdrawal
What are the non-pharmacological approaches to delirium
• 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
What are the pharmacological treatments used in delirium?
Antipsychotics:
- haloperidol
- olanzapine
- risperidone
- aripiprazole
- quetiapine
Benzodiazepines:
- lorazepam
- diazepam
Others:
- melatonin
- trazodone
- specific treatment of underlying cause
