Dementia and Delirium Flashcards
What is dementia?
Syndrome of generalised decline of memory, intellect and personality without impairment of consciousness
Leads to functional impairment
What are the risk factors for vascular dementia?
Stroke/TIA HTN AF DM Smoker Hyperlipidaemia
What are the two classifications of vascular dementia?
Stroke related: as a result of cerebrovascular disease
Small vessel related: due to arteriosclerosis
How does vascular dementia present?
What criteria is used for diagnosis?
Usually within 3 months of a stroke There is a stepwise decline - Emotional changes - Focal neurology - Poor concentration - Abnormal gait - Abnormal speech
NINDS-AIREN criteria
What is lewy body dementia?
Abnormal protein (Lewy bodies) deposition in the substantia nigra and neocortex leading to cholinergic and dopaminergic neurone loss
How and when does Lewy Body dementia present?
Occurs BEFORE parkinsonism features
Fluctuating course
- first difficulties are usually executive functioning and attention (not memory like other dementias)
- Visual hallucinations
How is Lewy Body dementia investigated and then managed?
What drugs must be avoided?
DaTscan
- rivastigmine or donepezil
- galantamine
- memantine
Avoid neuroleptics as can induce parkinsonism
What are the types of fronto-temporal dementia? What features are common to all 3?
Picks disease
Chronic progressive aphasia (CPA)
Semantic
All have a gradual onset
Memory is often preserved
Personality changes
No insight
What causes Picks disease and how does it present?
Picks bodies and fronto-temporal atrophy
- disinhibition
- impaired social conduct
- increased appetite
How does a) CPA and b) Semantic depression present?
CPA: speech as agrammatic and consists of short utterances that are non-fluent
Semantic: speech is fluent however is empty and meaningless. Memory is better for recent events compared to past
What screening/ investigations would you do in primary care for ?dementia
6 item cognitive impairment screen
10 point cognitive screener
TFTs (hypothyroid)
B12, folate, thiamine
Glucose
Calcium
What investigation would you do in secondary care for ? dementia and why?
Neuroimaging to rule out
- normal pressure hydrocephalus
- chronic subdural haematoma
- SOL
What are some differentials for dementia?
Huntingtons Parkinsons CJD HIV Chronic alcohol or barbiturate abuse Depression Hypothyroidism Normal pressure hydrocephalus Chronic subdural haematoma
What is important in the non-pharmacological management of dementia?
Group cognitive stimulation therapy Group reminiscent therapy Art, music, pet therapy DVLA Home safety Power of attorney and future care planning
What causes Alzheimer’s?
ACh deficiency
Neurofibrillary tangles (Tau tangles)
Beta amyloid plaques
Cortical and hippocampal atrophy
How does alzheimers progress? Timing and symptoms at each stage
Gradual decline
Early
- Problems remembering names and places
- Problem finding words
Moderate
- Global aphasia
- Apraxia (can’t carry out previously learned activities)
- Executive functioning (planning, problem solving)
Late/severe
- Agitation
- Incontinence
- Disorientation
What is the stepwise management of Alzheimer’s?
- donepezil or rivastigmine or galantamine
- memantine
- combination
What are the side effects of the acetylcholinesterase inhibitors?
How can one of these be managed?
Insomnia - manage with trazodone
Reduced appetite
Nausea, vomiting, diarrhoea
dizziness
What are the side effects of memantine?
Constipation
Dizziness
HTN
What is delirium?
Acute transient global organic disorder of CNS leading to impaired consciousness and attention
What are the types of delirium and how to they differ?
Hypoactive:
- Lethargic
- Decreased motor activity
- Apathy
- Sleepiness
Hyperactive:
- Agitated
- Irritable
- Aggressive
- Hallucinations/delusions
What are the key pre-disposing risk factors for delirium?
> 65yo
polypharmacy
significant injury
frailty
What are some causes for delirium?
Hypoxia - MI, PE, Cardiac failure
Endocrine - hypercalcaemia, hyper/hypoglycaemia
Infection - pneumonia, UTI, Meningitis
Intracranial - stroke, raised pressure, space-occupying lesion
Social - alcohol, drugs (could be same dose but lost weight = OD)
Abdo - Faecal impaction, malnutrition, urinary retention
Other - severe pain, sleep deprivation, anaesthetic, opioid
Nutrition - Thiamine, B12, nicotinic acid deficiency
How does delirium present?
D - disordered thinking (rambling and irrational) E - emotional (euphoric, fearful, angry) L - language (repetition, rambling) I - illusions and delirium (persecutory, tactile, visual) R - reversal of sleep (sleep in day) I - inattention (can't focus) U - unaware (to time, place and person) M - memory deficits
- It FLUCTUATES throughout the day
- There is impaired CONSCIOUSNESS (including hyperalert, drowsy, coma)
How is delirium managed?
- Treat underlying cause
- Reassurance and re-orientation
- Low dose haloperidol (not in Lewy-Body)
What is the difference between dementia and delirium?
Factor - Dementia vs Delirium Onset - Gradual vs Fast Duration - Months to years vs hours to weeks Course - slow progression vs fluctuations Consciousness - Intact vs Impaired Hallucinations - No vs Yes Delusions - Complex vs Fleeting Sleep - Normal vs Disrupted Attention - Normal vs Reduced Autonomics - Normal vs Disrupted
How is depression differentiated from dementia?
Depression has:
- rapid onset
- biological symptoms (Weight loss/sleep disturbance)
- mini mental state test can be variable
- global memory loss (vs dementia more recent)
