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Y4 OPIC > Dementia and Delirium, Capacity > Flashcards

Dementia and Delirium, Capacity Flashcards

1
Q

What are the important steps when taking a collateral history of potential cognitive decline?

A
  • First establish relationship to the patient.

HoPC:

  • onset, duration, fluctuation, step wise
  • Any triggers (e.g. infection, stress)
  • Associated symptoms (depression, hallucinations or delusions, behavioural changes, cognitive disturbance, sleeping patter changes)

PMH: head injury, BP, diabetes, parkinson’s, psych history

DH: BP, Diabetes, Parkinson meds, anything new, any allergies

FH: Depression, vascular disease, Dementia

SH: Living situation, carers, home support, ADLs, Working, Driving, Smoking and other cardiac risk factors

ICE for carer’s needs

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2
Q

What are the important Activities of Daily Living which need to be considered when assessing patients with cognitive impairment?

A
  • Washing
  • Dressing
  • Cooking
  • Cleaning
  • Shopping
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3
Q

How can you distinguish between dementia and delirium?

A 
Delirium is associated with...
- Sleep-wake cycle disruption
- Attention disruption
- Impaired Arousal
- Delusions and Hallucinations
- Reduced Consciousness
- Hyper or Hypo activity
….all are less common in Dementia.

Autonomic Dysfunction (e.g. Orthostatic dizziness, Syncope, Falls, Urinary Tract Symptoms, Constipation…) are seen commonly in Az and DLB but not delirium

Secondly, they differ in…

  • Duration (hours-weeks vs months-years)
  • Rate of Onset (abrupt vs insidious)
  • Course (fluctuating vs slow decline)
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4
Q

What are the most common causes of delirium?

A
  • Medications (or drug toxicity)
  • Alcohol or withdrawals
  • Strokes
  • Heart attacks
  • Liver disease
  • Low sodium/calcium
  • UTI
  • RTI
  • Constipation
  • Worsening of existing chronic illness
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5
Q

What routine investigations should be performed in a patient with suspected delirium?

A
  • Bloods (FBC, Us and Es, Cultures, BMs, LFTs)
  • Urine dip/MSU
  • PR
  • CXR
  • Confusion screening
  • Medication review
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6
Q

What are the five main screening tools for cognitive impairment?

A

AMT: Used for rapid assessment of cognitive impairment

MMSE: Longer screening tool used to assess for cognitive impairment in 30 questions

CAM: Diagnostic tool for delirium, based on 4 questions

MoCA: Probably the best for general use

Addenbrooke’s: Used most commonly in psych hospitals/dementia wards

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7
Q

How does CAM diagnose someone with delirium?

A 
1. Acute Onset
\+
2. Inattention
\+
3. Disorganised thinking OR/ 4. Altered levels of consciousness.
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8
Q

How do you manage Delirium?

A

Main aim = treat underlying cause and provide supportive care.

Supportive care:

  • Inform and involve family early on
  • Provide appropriate lighting
  • Clear signage with date and time
  • Cognitive stimulating activities
  • Adequate hydration, urination, lack of constipation
  • Reduce variation in environment and nursing staff

In emergency: Haloperidol.

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9
Q

Why is use of haloperidol controversial in delirium?

A
  • Useful short term at preventing patients from causing harm to themselves or others
  • Problematic as can prolong delirium episode as well as increase risk of subsequent episodes, and dementia risk long term
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10
Q

What is dementia, broadly?

A

Syndrome of generalised decline in MIP (memory, intellect, personality) without impairment of consciousness.

Leads to functional impairments including retention of new information, managing complex tasks, language, behaviour…

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11
Q

What causes Alzheimer’s?

A

Extracellular deposition of beta amyloid + intracellular accumulation of tau proteins

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12
Q

What causes Vascular Dementia?

A

Diseased blood vessels lead to reduction in blood flow to the brain leads to damage/death of neurons.

Can also happen immediately following a stroke.

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13
Q

What causes Lewy Body dementia and Parkinson’s disease with dementia

A

Abnormal deposits of a protein called alpha-synuclein form deposits in the brain called Lewy bodies

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14
Q

What causes FT dementia?

A

Selective brain atrophy affecting the frontal and temporal lobes

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15
Q

What are some causes of reversible dementia?

A
  • CNS infections (bacterial meningitis, neurosyphilis, TB, herpes, encephalitis, AIDS dementia complex)
  • Normal pressure hydrocephalus
  • CNS tumours
  • WK syndrome
  • Iron deficiency
  • Drugs
  • Depression
  • Sleep Apnoea
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16
Q

How do different dementias progress differently?

A

Az: Slow, gradual decline from MCI (approx. 7 years) to Mild Az (2 years) to Moderate Az (2 years) to Severe Az

VD: Step wise progression

LBD: Fluctuating course, some improvements and relapses

FTD: Progressive aphasia OR disintegration of personality and behaviour that can be misdiagnosed as psych disorder

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17
Q

What are the main risk factors for dementia?

A

Generic:

  • Older age
  • FH
  • Head injuries
  • Smoking
  • Depression
  • Sedentary lifestyle

Specific:

  • Az = Down’s Syndrome
  • VD = All cardiac risk factors, HTN, cholesterol, Diabetes
  • LBD = Male
  • FTD = Dyslipidaemia, Genetic mutations
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18
Q

What are the diagnostic criteria for Az?

A 
Decline in memory, learning, one other cognitive domain
\+
Steady gradual decline
\+
No evidence of mixed aetiology
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19
Q

What are the diagnostic criteria for VD?

A 
Memory Impairment
\+
Aphasia, Apraxia, Agnosia, EF disturbance
\+
Evidence of  cerebrovascular disease
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20
Q

What are the diagnostic criteria for LBD?

A 
Progressive decline
\+
2 of:
- Fluctuating alertness and thinking
- Repeated visual hallucinations
- Parkinsonian symptoms
- REM sleep behaviour
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21
Q

What management options are available for Az’s Dementia?

A

Cons: Activities to promote wellbeing, group cognitive stimulation, group reminiscence therapy, cognitive rehab

Pharm: Mild-Mod = AChE inhibitors (donepezil, galantamine) Severe = Memantine

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22
Q

What management options are available for Vascular Dementia?

A

Cons: Tackle risk factors (healthy, low fat low salt diet, lose weight, stop smoking, stop drinking)

Pham: BP meds, statins, aspirin, clopidogrel, anticoagulants all commonly used.
Az meds are NOT used in VD (can in mixed type).

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23
Q

What management options are available in Lewy Body Dementia?

A

Cons: Environmental modification (reducing clutter and distracting noises), Soothing responses rather than quizzing, Daily routines, Keeping tasks simple

Pharm: Dementia meds (Donepezil/Galantamine) + Parkinson’s meds (Carbidopa-Levodopa).

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24
Q

What management options are available in Parkinson’s with Dementia?

A

Cholinesterase drugs (e.g. donepezil), Antipsychotic drugs, Carbidopa-Levodopa

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25
Q

What management options are available in FT Dementia?

A

Largely supportive: Extensive counselling for families, future planning, involvement of social and health services. Pharm can be used with caution for behaviour management e.g. SSRIs or Olanzapine

26
Q

List 5 preventable causes of dementia?

A 
High BP
Sedentary life
Depression and Loneliness
Cognitive inactivity
Smoking and drinking
27
Q

What blood tests should be ordered to screen for organic causes of cognitive impairment in the elderly (either delirium or reversible dementia)?

A
  • FBC: Iron def anaemia
  • Us and Es: Electrolyte imbalance can cause CI
  • CRP: Infection
  • LFTs: Liver encephalopathy
  • Glucose/HbA1c: Hypo
  • Calcium: Hypo
  • Infection screen (Syphilis, HIV, TB, meningitis)
  • Vitamin B12/Folate/ Thiamine
  • Troponin: MI
  • TFTs: Raised TSH and low T hormones
28
Q

What cognitive tests can you perform face to face to judge a patient with suspected cognitive impairment?

A
  • AMTS: quick and easy
  • GPCOG: good in general practice
  • MoCA: Probably best screening tool for MCI and Az
  • CAM: Diagnostic for delirium
  • COGTEL: Good for other the phone

Diagnosis requires scans though.

Should also attempt to assess language function and executive function

29
Q

What is the main role of CT scanning in dementia patients?

A

Distinguishing between the different aetiologies.

30
Q

What is the classic CT sign seen in Alzheimer’s?

A

Cortical Atrophy

31
Q

What non pharmacological options are used in dementia?

A
  • Supportive care options to aid support patient e.g. memory aids, carers.
  • Aromatherapy
  • Multisensory stimulation
  • Animal assisted therapy
  • Massage
  • Music therapy
  • Physical exercise
  • Tailored activities
  • Therapy can manage difficult behaviours
32
Q

What is the difference between implied and expressed consent?

A

EC = valid consent given in writing or orally

IC = consent which occurs indirectly through the conduct or actions of the patient rather than through direct communication. It can be considered consent where a patient’s actions or lack thereof CLEARLY INDICATE their wishes.

33
Q

How is capacity defined?

A

One’s own ability to make decisions involving welfare, healthcare and finances.

Mental capacity is both time specific (can vary from day to day, hour to hour, therefore must always be acquired close to the intervention being carried out) and decision specific (capacity can vary between different decisions, therefore should be re-acquired for each new procedure)

34
Q

What are the two goals of the Mental Capacity Act 2005?

A

The act aims to:

  • empower people to make decisions for themselves where possible and…
  • protect people who lack capacity by providing a suitable, flexible framework that puts their needs at the heart of any decision making process.
35
Q

When might people lack capacity (and therefore come under the remit of the MCA)?

A

Broadly: Anyone with a disturbance to the mind or brain (e.g. Sz, Bipolar, Learning difficulties, dementia, brain damage, physical conditions that might cause drowsiness, intoxication)

36
Q

What are the 5 principles of the MCA 2005?

A
  1. Presume any patient has capacity.
  2. Individuals should be supported to make their own decisions (healthcare workers must do everything in their power to assist people in making decisions for themselves)
  3. People have a right to make unwise decisions, this does not indicate a lack of capacity

In case someone does not have capacity, decisions must be made according to…

  1. Best interest (if lack capacity, choose best option)
  2. Least restrictive (if lack capacity, choose least restrictive option)
37
Q

What is the two-stage Capacity Test?

A

Quickfire way of assessing a person’s capacity?

Stage 1: Does this person have an impairment or disturbance in the functioning of their mind or brain? If yes Stage 2…

Stage 2:

  • Can they UNDERSTAND the information about the decision
  • Can they RETAIN that information
  • Can they USE or WEIGH UP that information in the decision process
  • Can they COMMUNICATE their decision

N.B: The two stages exist because not everyone with an impairment to their thinking lacks capacity.

38
Q

What is a Legal Power of Attorney?

A

Legal document in which the ‘donor; appoints one or more people (‘attorneys’) to help make decisions on their behalf. Two kinds; health and welfare + property and finances.

39
Q

What is a Deputy appointed by the Court of Protection?

A

Essentially a LPA appointed by the Court of Protection when no LPA is in place and a person lacks mental capacity. Powers of the deputyship are laid out by the court, can include financial, legal, property powers._

40
Q

What is a Public Guardian?

A

Government office which enacts the MCA (2005) when there are concerns about capacity, attorneys, deputies or guardians. Helps people plan for someone to make decisions or them while also supporting and empowering them to make their own for as long as possible. Also responsible for supervising court appointed guardians and looking into abuse by guardians.

41
Q

What are Advanced Decisions to Refuse Treatment?

A

A legal document made at any time to refuse a specific type of treatment at some time in the future. Normally used on life sustaining treatment e.g. ventilation, CPR, antibiotics.

42
Q

What is an Independent Mental Capacity Advocate (IMCA)?

A

Support people when they are assessed to lack capacity to make a best interest decision and they have no family or friends appropriate to consult about the decision. Decisions can be made about long-term accommodation as well as serious medical treatment

43
Q

What is an Independent Mental Health Advocate (IMHA)?

A

IMHAs support people with issues relating to their mental health care and treatment. They also help people with mental health issues understand their rights under the MHA.

44
Q

What is the purpose of a Deprivation of Liberty Safeguard?

A

Aim of the DOLS is to make sure that people who lack capacity are looked after in a way that does not inappropriately restrict their freedom.

45
Q

What does the Mental Health Act (1983, 2007) allow for?

A

People in England and Wales with a mental disorder to be sectioned (i.e. admitted to hospital), detained and treated without their consent either for their own health and safety or for the protection of other people.

46
Q

What are the important sections of the MHA?

A

2, 3, 5(2), 5(4), 136, 135, 117 + Community Treatment Order

47
Q

What is a Section 2?

A

Patients can be detained under section 2 if they; have a mental disorder + need to be detained for a short time for assessment/medical treatment + it is necessary for their own health and safety or for the protection of other people. Lasts 28 days.

48
Q

What is a Section 3?

A

Patients can be detained under Section 3 if they; have a mental disorder + need to be detained for their own health and safety or for the protection of others + treatment can’t be given unless they are detained in hospital. Lasts 6 months, many individuals first get section 2’d then after assessment get section 3’d

49
Q

What is a Community Treatment Order?

A

If a patient has been sectioned and treated in hospital, a responsible clinician can put them under a CTO, meaning they can be discharged for care in the community but under certain conditions. These often include living in a given place, receiving a certain treatment… If these terms are broken the patient can be readmitted

50
Q

What is a Section 5(4)?

A

Section 5(4) applies to voluntary patients receiving treatment for a mental disorder as an inpatient. These last 6 hours, and are implemented by NURSES trained and qualified in work with mental health or LD patients, ordered if patient needs to be kept in hospital immediately for their health and safety or that of others and a clinician isn’t available. Short term solution, after 6 hours should be assessed by clinician for potential section 5(2).

51
Q

What is a Section 5(2)?

A

This section applies to patients who are voluntary patients or inpatients. Doctors or other approved clinicians in charge of treatment make this detention section if there is a need to keep the patient in hospital for their own safety. Lasts 72 hours

52
Q

What is a Section 136?

A

Made by police when they feel a person has a mental disorder and needs to be kept at a place of safety. Lasts 24 hours but can be extended to 36.

53
Q

What is a Section 135?

A

Patients can be placed under section 135 if there is reasonable cause to suspect they have a mental disorder and are either being ill-treated or neglected OR are unable to care for themselves and live alone. Issued by a magistrate, carried out by a police officer with a mental health professional who take the patient to a place of safety. Lasts 24 hours (can be extended to 36).

54
Q

What is a section 117?

A

Under this section, health authorities and local social services have a legal duty to provide free aftercare for people who have been discharged under the MHA. Aftercare services aim to meet needs relating to their mental health problems and should prevent a deterioration in mental health that would mean they had to return to hospital.

55
Q

What is the purpose of a DNACPR?

A

The purpose of a DNACPR decision is to provide immediate guidance to those who are looking after an individual (in healthcare/social care settings) on the best action to take or not to take should a patient suffer a cardiac arrest or die suddenly.

56
Q

What are the benefits of a ReSPECT form over a DNACPR?

A
  • ReSPECT form goes further than DNACPR
  • Provides patients with a sliding scale of options, trade off between interventions that will maximise life length and those that will maximise comfort
  • Supposedly easier to discuss, more standardised
  • Allows patients to dictate their own ceiling of care e.g. i would like to be bought in to hospital for blood products or antibiotics, but i would not like CPR or to be treated for cancer recurrence…
57
Q

What is meant by ceiling of healthcare?

A

The absolute highest degree of life-saving/prolonging invasive intervention a patient has agreed to consent to, anything beyond this they would not want.

E.g. A person’s ceiling of care might be admission to hospital for IV antibiotics, blood products of fluids, anything beyond this should be avoided.

58
Q

What is involved in a comprehensive End of Life Care plan?

A
  • Review of medication, aiming to eliminate polypharmacy
  • Planning of patient and clinical priorities e.g. symptom control vs curative treatment
  • Working out where the patient would like to receive care e.g. in the home vs care home vs relative’s vs hospital
  • Legal documentation e.g. ACP, Advanced Decision to Refuse Treatment, Will, LPA
  • Symptom management: breathlessness, pain, constipation, nausea, agitation, respiratory secretions.
59
Q

What medications are commonly given in end of life care?

A

Medications commonly given in End of Life Care include:
Analgesics; Morphine, Diamorphine, Oxycodone
Antiemetics; Haloperidol, Levomepromazine, Cyclizine
Antisecretory agents; Glycopyrronium,Hyoscine Butylbromide
Sedatives and Relaxants; Lorazepam, Midazolam
Constipation; Range of laxatives can be given.
Dry Mouth; Nystatin
Anorexia; Prednisolone

60
Q

What is the Home First approach?

A

Approach/framework within the NHS which aims to offer people at home or intermediate care (e.g. community hospital) rather than hospital admission.

Useful for the management of delirium, as sending patients into hospital to receive care can often worsen things, care at home or in comm hospitals associated with faster recovery.

Y4 OPIC (5 decks)

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