Dementia and delirium Flashcards
Define delirium
An acute confusional state that fluctuates in severity and is usually reversible. Usually due to an organic problem.
Define dementia
A syndrome of acquired, generalised decline in memory, intellect and personality without impairment of consciousness (ie in an alert patient) which results in functional impairment
List some behavioural and psychological symptoms of dementia
agitation irritability depression disinhibition hallucinations
What are the risk factors for developing delirium?
older age dementia significant comorbidites sensory impairment change in environment
What are the causes of delirum?
Can say anything here and it we be correct!
rep failure, heart failure, MI, PE
hyoerthyroidism ,hypothyroidism, hyper/hypoglyaemia
OPneumonia, UTI, meningitis
Stroke, head trauma, space occupying lesion
Pain
Post op - anaesthetics, opiates
Urinary retention, faecal impaction
Alcohol withdrawal - delirium tremens
drugs - anticholinergics, opiods, benzos, steroids, antiparkinsons drugs
Which is first line treatment for delrium? Pharmacological or non-pharmacological?
Non-pharmacological
How would you manage delirium?
Non pharmacolofical
- orientation: time and place, clocks, calenders
- reassurance
- provide hearing aids, glasses
- relatives to visit
- consistency in caring staff eg nurses
- well lit side room
Pharmacological
- treat underlying cause eg infections
- low dose haloperidol or olanzapine
What is the prognosis for delirium?
1/3 recover to baseline quickly
1/3 recover but much slower
1/3 never recover to baseline (these pts may have underlying dementia)
What are the reversible causes of dementia?
Normal pressure hydrocephalus
B12 or folate deficiency
Hypothyroidism
What are the symptoms of hypoactive delrium?
slowness with tasks
lethargy
Excess sleeping
Inattention
Define delirium
Acute, transient, global disorder of CNS functioning resulting in impaired consciousness and attention and of organic origin
List 5 causes of delirium
HE IS NOT MAD
Hypoxia - resp failure, heart failure, PE
Endocrine - hyper/hypothyroidism, hyper/hypoglycaemia
Infection - pneumonia, UTI
Stroke and neuro - stroke, space-occupying lesion, head trauma
Nutritional - low B12
Others - severe pain, sleep deprivation
Theatre (post-op) - anaesthetic, opioids
Metabolic - hyponatraemia
Abdominal - faecal impaction, urinary retention
Alcohol - intoxication, withdrawal (delirium tremens)
Drugs - benzodiazepines, opioids, anticholinergics, Parkinson’s meds, steroids
What are the risk factors for delirium?
- older age ≥65
- male
- previous episodes of delirium
- multiple comorbidities
- frailty
- renal impairment
- recent surgery
- severe illness
What are the clinical features of delirium?
Acute onset
fluctuating course - worse at night
DELIRIUM
- disordered thinking - slow, irrational, incoherent thoughts
- emotional disturbance - euphoria, anger, depression, fear
- language - rambling, repetitive, disruptive
- illusions - delusions, hallucinations (tactile, visual -
- reversal of sleep wake pattern
- inattention -inability to focus, clouding of consciousness
- unsure/disorientated - time, place, person
- Memory deficits
Think of the categories of the 4AT to help with this
What are the ICD criteria for delirium?
Impairment of consciousness and attention Global disturbance in cognition Psychomotor disturbance Disturbance of sleep-wake cycle Emotional disturbance
List 5 differences between delirium and dementia
Delirium Vs dementia
Duration - hours to weeks vs months to years
Onset - acute/subacute vs chronic
Course - fluctuating vs slowly progressive
Consciousness - impaired vs not impaired
Halluciantions - common vs less common
Psychomotor activity - abnormal vs normal
Attention - markedly reduced vs normal/reduced
Sleep wake cycle - disrupted vs usually normal
What would you do in terms of examination for a pt with suspected delirium?
ABCDE GCS Vital signs Cardio, resp, abdo and neuro exam Check for urinary retention and faecal impaction (PR if possible) Nutritional and hydration status
What might be the MSE findings of sb with delirium?
Appearance and behaviour – hypo or hyper alert. Agitated, aggressive or purposeless behaviour
Speech – incoherent, rambling
Mood – low mood, irritable or anxious, often labile
Thought – confused, ideas of reference, delusions
Perception – illusions, hallucinations (mainly visual), misinterpretations
Cognition – disorientated, impaired memory, inattention, reduced level of consciousness
Insight – poor
What questionnaire is the main one used for delirium?
4AT
What basic investigations would you do for delirium?
Confusion bloods: -o FBC – infection, anaemia o CRP o U+Es – electrolyte disturbance, renal impairment o LFTS – alcoholism, liver disease o Calcium – hypercalcaemia o Glucose – hypo or hyperglycaemia o TFTs o B12, folate, ferritin – nutritional deficiencies Urinalysis - for UTI CXR - infection Blood culture - sepsis ECG - arrhythmia, MI
What further investigations might you consider in delirium depending on what you are looking for?
ABGs - hypoxia
CT head - head injury, intracranial bleed, stroke
lumbar puncture - meningitis
EEG - epilepsy
Name 4 differentials for delirium
Depression (hypoactive delirium often misdiagnosed as depression)
Dementia
Late onset schizophrenia
Hypo/hyperthyroidism
How would you manage delirium?
Non-pharmacological is the mainstay
Biological
- Treat underlying cause eg antibiotics, fluids, laxatives
- Encourage oral intake
- Antipsychotics (last resort)- only used if very distressed, eg Olanzapine or Haloperidol (DON’T use benzos unless it is delirium tremens)
- remove catheters and cannulas if unnecessary
- refer to geriatrics consultant
Psychological
o Distraction techniques – chat to patient, talk about more familiar things eg job, family
o Clock and calendar for orientation
o Move to side room or a bay if preferred
o Reassurance
o Glasses or hearing aids
o Continuity of care with same staff
Social
o Let family visit and ask them to bring familiar items
Define dementia
A syndrome of generalised decline of memory, intellect and personality without impairment of consciousness, leading to functional impairment
Remember the 3 components to the definition above
What are the common causes in order of how common they are?
- Alzheimer’s dementia
- Vascular and mixed
- Dementia with Lewy bodies
- Frontotemporal dementia
- Others - infections, alcohol, normal pressure hydrocephalus, vitamin deficiencies
Explain the pathophysiology of Alzheimer’s disease
- Neurofibrillary tangles (intracellular)
- Beta amyloid plaques (extracellularly)
- Cortical atrophy (commonly hippocampal) with widened sulci and enlarged ventricles
- degeneration of cholinergic neurons leading to deficiency of acetylcholine
Explain the pathophysiology of vascular dementia
• Stroke, multi-infarcts or chronic changes eg arteriosclerosis
Explain the pathophysiology of Lewy body dementia
- Abnormal deposition of Lewy Bodies (proteins) in the brainstem, substantia nigra and neocortex
- Leads to cholinergic loss, dopaminergic loss and Parkinsonism
Explain the pathophysiology of frontotemporal dementia
- Atrophy of the frontal and temporal lobes
* One type of frontotemporal dementia is Pick’s disease, where protein tangles (Pick’s bodies) are see histologically
Which of males or females are more likely to get Alzheimer’s disease?
females
Which of males or females are more likely to get vascular/mixed dementia?
males (think of it as males are more likely to have cardiovascular risk factors and events)
Name 4 risk factors for development of Alzheimer’s disease
- increasing age
- family history
- down’s syndrome
- vascular risk factors - previous stroke or MI, smoking, hypertension, diabetes, high cholesterol
Name 5 irreversible causes of dementia
Neurodegenerative
- Alzheimer’s
- Vascular
- Mixed
- Lewy body dementia and Parkinson’s disease dementia
- Frontotemporal/Pick’s disease
- Huntington’s disease dementia
Infectious
- HIV
- syphilis
- CJD
Toxins
- alcohol
Vascular
- stroke and vascular dementia
Traumatic head injury
Name 5 reversible causes of dementia
Neurological
- normal pressure hydrocephalus
- chronic subdural haematoma
Vitamin deficiencies - B12
Endocrine - Curshing’s, hypothyroidism
Which dementias are cortical?
Alzheimer’s (get cortical atrophy)
Frontotemporal (remember affects frontal and temporal lobes)
Which dementias are subcortical?
Lewy body (remember it causes parkinsonism so think of this like the basal ganglia being affected)
Which dementias affect the cortex and subcortex?
Vascular - remember can get a stroke anywhere
Name 5 differences between cortical and subcortical dementias
Cortical Vs subcortical
Memory loss - severe vs moderate
Mood - normal vs low
Speech and language - early apahsia vs dysarthria
Coordination - normal vs impaired
Praxis (performing voluntary skilled movements) - apraxia vs normal
Motor speed - normal vs slow
What are the ICD-10 criteria for diagnosing dementia?
- Decline in memory for at least 6 months (usually short-term memory)
- Decline in cognition in planning and organising
- Decline in emotional control or motivation or a change in social behaviour:
a. Emotional lability
b. Irritability
c. Apathy
d. Coarsening of social behaviour
so MEMORY, COGNITION, EMOTIONS
What types of impairments can you get in dementias?
Memory Cognition Language Emotions Executive function (concentration, inhibitory control, reasoning, problem solving) Visuospatial Personality Non-cognitive - BPSD- hallcuinations, aggression, wandering, depression, apathy, delusions
What are the 5 A’s of Alzheimer’s disease
Amnesia
Apraxia - Inability to carry out previously learned movements eg dressing, using a knife and fork
Agnosia - unable to recognise objects eg a fork
Anomia - word finding problems
Aphasia (global)- problems understanding (receptive) and producing (expressive) speech and reading/writing
What are the clinical features of Alzheimer’s disease?
5As, DISORIENTATION, EXECUITIVE FUNCTION, VISIOSPATIAL, LANGUAGE, BPSD
Amnesia
Apraxia - Inability to carry out previously learned movements eg dressing, using a knife and fork
Agnosia - unable to recognise objects eg a fork
Anomia - word finding problems
Aphasia (global)- problems understanding (receptive) and producing (expressive) speech and reading/writing
Disorientation to time and place
Problems with executive function Problem solving Abstract thinking Reasoning, Decision making and Judgement Planning, Organisation and Processing
Visuospatial abilities
Getting lost
Impaired driving
Copying figures
Language disturbance Word finding (Anomia) Decreased vocabulary Perseveration Global Aphasia – impairment of production and comprehension of speech and ability to read and write
Agnosia
Impaired recognition of sensory stimuli eg unable to recognise a fork
Non-cognitive (BPSD) o Hallucinations o Delusions o Emotion – depression, apathy o Behaviour - wandering, aggression
What are the clinical features of vascular dementia?
STEPWISE, UMN SIGNS,CARDIOVASCULAR DISEASE, PERSONALITY CHANGE, EMOTIONS
STEPWISE deterioration
UMN signs – spastic weakness, increased reflexes extensor plantar response (remember they have had repeated strokes)
Signs of cardiovascular disease elsewhere
Personality changes occur earlier than memory loss
Memory loss
Emotional changes – depression, apathy
What are the clinical features of mixed dementia?
Features of both Alzheimer’s and vascular dementia
What are the clinical features of dementia with Lewy bodies?
HALLUCINATIONS AND PARKINSONISM
Day to day fluctuations in cognitive performance
Visual hallucinations
Parkinsonism (tremor, rigidity, bradykinesia)
What is the difference between dementia with lewy bodies and parkinson’s disease dementia?
Lewy body - Dementia and parkinsonism occur within 12 months of each other
Parkinson’s disease dementia – pts who already have Parkinson’s disease develop dementia more than 12 months later)
What are the clinical features of frontotemporal dementia?
PERSONALITY AND LANGUAGE
Occurs within the ages of 50 and 60 – develops insidiously
Early personality changes – disinhibition, apathy, restlessness, worsening social behaviour, repetitive behaviour
Language problems – word finding, anomia, receptive apahasia
Memory persevered in early stages, but insight lost early
Family history positive in 50%
What are the clinical features of Huntington’s disease dementia?
Abnormal choreiform movements of face, hands, shoulders and gait
Dementia presents later
Strong FH
What is the triad of normal pressure hydrocephalus?
Triad:
- Dementia
- Urinary incontinence
- Gait disturbance
Onset after 70
What are the clinical features of CJD?
NEURO SIGNS, HIGHER CEREBRAL DYSFUNCTION
Onset before 65
Rapid progression with death in 2 years
Disintegration of all higher cerebral functions
Dementia + neurological signs – pyramidal, extrapyramidal and cerebellar
What are the key areas to ask about when taking a dementia history?
NEED COLLATERAL HISTORY
MEMORY, LANGUAGE, VISUOSPATIAL, FUNCTION
• Memory: Do you find yourself forgetting things? Can you give some examples?
• Anomia/language: Do you find you forget familiar people’s names?
• Visuospatial: Do you get lost more easily than you used to?
• Functional impairment: Do you think being forgetful is stopping you from doing anything? Are you able to handle money confidently? Ask about: money, dressing, cooking continence, self-care, shopping/housework orientation and safety,
• COLLATERAL - repetitive in conversation, memory, personality, safety concerns
PMH - known dementia, seen memory clinic?
DH - any dementia medication, anticholinergic burden, drugs and alcohol
SH - social and home support, safety
Describe a typical MSE of someone with dementia
Appearance and behaviour: unkempt, poor self-care, inappropriate behaviour eg in fronto-temporal, uncoordinated, restless
Speech – slow, confused, difficulty finding right word, repetitive
Mood – low or normal, disturbance of affect more common in vascular
Thought – delusions may be present
Perception – visual hallucinations especially in lewy body dementia
Cognition – affected in all dementias to varying degrees, memory impairment is most severe in cortical dementias
Insight – may be preserved initially, but is lost later on
How would you take a history in delirium and what would you ask about?
Much of the history may be COLLATERAL
- What were they like before this episode? How was their memory and how long has it been poor for? What was their functioning like before?
From pt/staff
- When did the pt start to get confused?
- What was the course of the confusion?
- Any symptoms suggestive of an underlying cause? eg suprapubic pain
- Are they more or less alert than usual?
- Hypersensitivity to sound and light?
- Illusions or hallucinations?
- Full drug and alcohol history – considering delirium tremens (alcohol withdrawal) or drug-induced psychosis
What investigations would you do for dementia?
FBC – infection, anaemia CRP – infection, inflammation U+Es – renal disease Calcium – hypercalcaemia LFTs – alcoholic liver disease Glucose – hypoglycaemia Vit B12 and folate – nutritional deficiency TFTs - hypothyroidism
What further investigations for dementia would you consider doing dependent on the examination findings?
Urine dipstick - UTIs CXR – pneumonia, lung tumour Syphilis serology and HIV testing (only if there are atypical features or special risks) Brain imaging indicated if: • Early onset <60 yrs • Sudden decline • High risk of structural pathology • Focal CNS signs or symptoms • Monitoring disease progression
Brain imaging:
• CT scan – 1st line, hippocampal atrophy
• MRI – vascular pathology
• SPECT – rarely used, aims to differentiate between Alzheimer’s disease, vascular dementia and dementia with Lewy bodies
ECG – if cardiovascular disease suspected, eg AF
EEG – if frontotemporal lobe dementia or CJD is suspected, or seizures
Lumbar puncture – meningitis, CJD suspected
Genetic tests – Huntington’s disease
What are the 2 commonest tests for dementia used within the hospital and secondary care?
Mini Mental State Examination (MMSE)
Addenbrooke’s cognitive examination (ACEIII)
Name 4 differentials for dementia
- Normal aging and mild cognitive impairment
- Delirium
- Stroke
- Traumatic brain injury
- Depression (pseudodementia) – identify whether the low mood or poor memory came first
- Late onset schizophrenia
- Wernicke’s encephalopathy (delirium, nystagmus, ophthalmoplegia, hypothermia, ataxia)
- Korsakoff’s psychosis (also known as amnesic syndrome) – profound, irreversible short-term memory loss with confabulation and disorientation to time
- Substance misuse
- Drug side effects: opiates, benzodiazepines, anticholinergic drugs
What are the driving regulations for someone with a diagnosis of dementia?
Pts are required to contact the DVLA after a diagnosis of dementia is made – they may be able to continue driving subject to annual reports and annual review
Licence revoked at diagnosis for HGV driver or passenger carrying vehicles
How can vascular dementia be modified?
modify cardiovascular risk factors
Would you use the mental health act or mental capacity act for someone with dementia?
Mental Capacity Act
What is the pharmacological management of dementia?
Acetylcholinesterase inhibitors – Donepazil, Rivastigmine, Galantamine. Increase Ach in cerebral cortex and hippocampus
o Mild to moderate AD
o Dementia with Lewy Bodies
NMDA antagonist - Memantine
o Moderate AD in pts who are intolerant or have a contraindication to Acetylcholinesterase inhibitors
Antidepressant – for low mood eg Sertraline
Behaviour that challenges
o Short course of antipsychotic eg risperidone (BUT NOT in dementia with Lewy bodies as can cause severe adverse effects, neuroleptic malignant syndrome and worsening of extrapyramidal features)
What is the non-pharmacological management of dementia?
Promote independence
Driving assessment and ask pt to tell DVLA
Post diagnostic counselling, CBT
Social support
o support groups from Alzheimer’s society
o Arts for dementia
o Reading Well Books on Prescription for dementia
o Online websites, Online forums - Talking Point is the Alzheimer’s Society’s forum..
o Dementia Cafes
Support at home
o community dementia teams
o home nursing and personal care
Community services o meals on wheels o befriending services o day centres o respite care o care homes o Admiral nurses (like Macmillan nurses for cancer) o Charities – Alzheimer’s Society, Dementia UK, Age UK, Carers UK
Behaviour that challenges
o therapeutic music
o animal therapy
Carer support
o Carers UK
o Carers assessment by GP
o Carers allowance
o Advice on how to look after their own health
o Planning enjoyable activities to do with the person they care for
o Information about relevant services and psychological support
What is age-associated memory impairment?
Recall or learn info more slowly, but given time, their performance is unchanged
Only less important facts forgotton
Pt more bothered by it than family
Mainly memory impairment, other aspects of cognition not affected
Can present early in 40s-50s
(not a condition or disease)
What is mild cognitive impairment?
Impairments are more broad than memory alone
Patient feels this is pathological, but the full criteria for dementia are not yet met, eg no functional impairment
What proportion of patients with mild cognitive impairment progress to dementia?
Progression to dementia occurs in 5-10% only, many do not deteriorate (but have read elsewhere that progression is 50%)
Refer to memory clinic as a GP, Monitor as a GP and modify risk factors
What tool can you use to gauge sb’s severity in functional impairment in dementia?
the FAST tool - lists a range of functional activities eg bill paying, eating and then gauges severity from which activities the pt can’t do
What factors would make you think that a pt has dementia rather than delirium?
o KNOWN DEMENTIA?
o LONGER THAN 6 MONTHS
o PHYSICAL CAUSE been ruled out
o PERSISTENT agitation, psychosis or apathy?
What factors might make BPSD worse?
- delirium
- drugs - anticholinergic burden, sie effects, drugs not prescribed
- alcohol
- pain - undertreated/not recognised
- tiredness, hunger, thirst
- relocation, trying to go home
- XS noise, poor lighting, busy
- social isolation
- spiritual and cultural needs
- unable to express needs/new symptoms
What does clock drawing test?
Visuospatial
Executive function and planning
Attention and memory
Language
Name some alternative cognitive function questionnaires in dementia
6CIT - very popular with GPs
GPCOG - used in GP
MoCA- used in hospital
List 4 differences between depression and dementia
Depression vs dementia
Onset - sudden vs insiduous
Course - can be chronic, relapses vs progressive
Reversibility - usually reversible vs irreversible
What members of the MDT may be involved in caring for a pt with dementia?
Older Acute Mental Health Team OT - support at home, activities SaLT - language, swallowing GP Admiral nurses District nurses Physio
What prevention strategies can we promote for dementia prevention and for pts with mild cognitive impairment?
o Physical activity – delays cognitive impairment, improves balance and strength
o Cognitive exercises – neuroplasticity, regeneration of the brain
o No smoking or alcohol
o Improve diet
o Lose weight
o Treat hypertension and hypercholesterolaemia
List some effects of being a carer
• Stress and worry- spend a lot of time thinking about their illness and the impact it is having on both of your lives.
• Social isolation - You may feel like your life is very different from other people’s, and that they don’t understand how you are feeling. May feel guilty about making time for yourself
• Financial worries and debt - gave up work
• Physical health problems - back pain, comorbidities
• Depression
• Frustration and anger – giving up work, pressure of caring
• Low self-esteem
- sleep deprivation
- often from lower income or have health problems themselves
What are the aspects tested by the 4AT?
Alertness - hypo or hyperactive
AMT4 - PADY - Place, Age, DOB, Year
Attention - Months of the year backwards
Acute or fluctuating course
How can you prevent delirium?
• Avoid moving pts
• Care given by the same healthcare professionals
• Assess pts within on day of admission with clinical factors putting them at risk of delirium
• Appropriate lighting
• Clear signage
• Clock
• Introducing yourself to pt clearly – who you are, what is your role
• Regular visits from family and friends
• Management of dehydration and constipation – give adequate fluids
• Infection
o Avoid unnecessary catheterisation
o Look for and treat infection
• Encourage pts to mobilise soon after surgery
• Medication review
• Address poor nutrition
• Visual and hearing aids
