Dementia and derlirium Flashcards
What is a DOLS realted to?
Mental capacity act
What is the ACE tool?
Test for cognitive impariments in disorders like dementia
Sections in ACE tool
Memory - 18
Attention - 18
Fluency - 14
Language - 26
Visuospatial -16
Score out of 100
What lobes are affected in frontotemporal dementoa?
Frontal and temporal lobes
What is loss of function in the temporal lobe ass with?
Language problems
What is chnages in the frontal lobe ass with?
Behavioural changes eg disinhibiiton, personality change
What lobes are ass with alzeihmers dementia affected in functional scan?
temporal and parietal lobes esp
How does a fTG PET scan work?
Carbon 13 glucose metabolism - isotope picked up on scan to see levels of metabolism in different areas of teh brain
What dementias are ass with lewy bodies?
Alzeihmers
Lewy body dementia
Causes of memory or concentration difficulties in under 50s
-recreational, and some prescription, drugs
－ alcohol
－ affective disorders
－ stress.
- ADHD
- Anxiety
What to tell people when they’re diagnosed with dementia
what their dementia subtype is and the changes to expect as the condition progresses
which healthcare professionals and social care teams will be involved in their care and how to contact them
if appropriate, how dementia affects driving, and that they need to tell the Driver and Vehicle Licensing Agency (DVLA) and their car insurer about their dementia diagnosis
their legal rights and responsibilities
Advance carew planning
their right to reasonable adjustments (in line with the Equality Act 2010) if they are working or looking for work
how the following groups can help and how to contact them:
local support groups, online forums and national charities
financial and legal advice services
advocacy services.
What to do on initial assessment for dementia?
from the person with suspected dementia and
if possible, from someone who knows the person well (such as a family member).
Conduct physical exam
undertake appropriate blood and urine tests to exclude reversible casuses cognitive decline
What to do on initial assessment for dementia?
from the person with suspected dementia and
if possible, from someone who knows the person well (such as a family member).
Conduct physical exam
undertake appropriate blood and urine tests to exclude reversible casuses cognitive decline
Cognitive testing screens
the 10-point cognitive screener (10-CS)
the 6-item cognitive impairment test (6CIT)
the 6-item screener
the Memory Impairment Screen (MIS)
the Mini-Cog
Test Your Memory (TYM).
When refer person to specialist dementia service
Reversible causes cognitive decline eg delirium or from meds ruled out
Dementia is still suspected
What medications can mimic demnetia
Increased antih=cholinergic burden
What to rule out if rapidly deteriorating dementia
Creutzfeldt-Jakob disease and similar conditions
CSF investigations
When include verbal episodic memory test in the assessment?
Alzeihmers suspected
When to do neuropsychological testing
whether the person has cognitive impairment or
whether their cognitive impairment is caused by dementia or
what the correct subtype diagnosis is.
What are the diagnosis for primary progressive aphasia ?
Inclusion
Most prominent clinical feature is language difficulty
Deficits are principal cause of impaired ADLs
Aphasia should ne the most prominent deficit at symptoms onset and intial phase of disease
Exclusion
Pattern or deficits better accounted for by other diagnossis
Cognitive the same
Prominent intial episodic memory, visual memory, visuoperceptual impairments
Prominent, inital behavioural disturbance
Types o frontoemtporal dementia
Progressive non fluent aphasia
Semantic dementia
Behavioural variatn
Primary progressive aphasia inclusion criteria
Most prominent clinical feature must be difficulty in language
Must cause impairment of ADLs
Aphasia must be most prominent at symptom onset and early stage of disease
Semantic variatn of PPA criteria for diangosis
Both of following must be present:
Impaired confrontation namin
Impaired single word comprehehnsion
At least 3 of the following:
Impaired object knowledge, particuarky for low frquency or low familiarity items
Surface dyslexa or dysgrapgi
Spared repetition
Spared repetiion
Spared speech production (grammar and motor speech)
Imaging supported criteria semantic variant PPA diagnosis
Predominant anterior tmeporal lobe atrophy
Predominant anterior temproal hypoperfusion or hypometabolism on SPECT or PET
Pathology of semantic variant of PPA with definitie pathology criteria
hISTOPATHOLOGIC EVIDENCE OF NEURODEGEN PATHOLOGY EG tau, TDP, Alzeihmers
Presence of known pathogenic mutation
Possibel FTLD criteria
3 of the follwoing
A - early behavioural disinhibition
B - Early apathy or intertia
C - Early loss of sympahy or empathy
D - Early perseverative, stereotyped or compulsive/ritualistic behaviour - Simple repetitive movement, complex compulsive or ritualistic behaviours, Stereotypy of speech
E - Hyperorality and dietary changes
F - Neuropsychological profile - executive/generation deficits with relative sparing of memory and visuospatial functions - Deficits in executive tasks, Relative sparing of episodic memory, sparing of visuospatial skills
Behavioural disinhibition examples
Socially innapropriate behaviour
Loss of manners or decorum
Impulsice, rash, careless
Signs of decreased empathy or sympathy
Diminished response to other peoples needs and feelings
Diminished social interest, interrelatedness or personal warmth
Signs of decreased empathy or sympathy
Diminished response to other peoples needs and feelings
Diminished social interest, interrelatedness or personal warmth
Hyperorality and dietary changes in FTLD
Altered food preferences
binge eating, increased consumption of alcohol or cogs
Oral exploration or consumption of inedible objects
Probable FLTD
Meets criteria for possible FLTD
Significant functional decline
Imaging results consistent with FLTD
Exclusionary criteria for FLTD
Patern if deficits better accounted for by another disorder
Beahviour - ^
Biomarkers strnigly indicate alzeihmers
Core clinical criteria for dementia
Interfere with the ability to function at work or at usual activities; and
Represent a decline from previous levels of functioning and performing; and
Are not explained by delirium or major psychiatric disorder;
Cognitive impairment is detected and diagnosed through a combination of (1) history-taking from the patient and a knowledgeable informant and (2) an objective cognitive assessment, either a “bedside” mental status examination or neuropsychological testing. Neuropsychological testing should be performed when the routine history and bedside mental status examination cannot provide a confident diagnosis.
The cognitive or behavioral impairment involves a minimum of two of the following domains:
Impaired ability to acquire and remember new information—symptoms include: repetitive questions or conversations, misplacing personal belongings, forgetting events or appointments, getting lost on a familiar route.
Impaired reasoning and handling of complex tasks, poor judgment—symptoms include: poor understanding of safety risks, inability to manage finances, poor decision-making ability, inability to plan complex or sequential activities.
Impaired visuospatial abilities—symptoms include: inability to recognize faces or common objects or to find objects in direct view despite good acuity, inability to operate simple implements, or orient clothing to the body.
Impaired language functions (speaking, reading, writing)—symptoms include: difficulty thinking of common words while speaking, hesitations; speech, spelling, and writing errors.
Changes in personality, behavior, or comportment—symptoms include: uncharacteristic mood fluctuations such as agitation, impaired motivation, initiative, apathy, loss of drive, social withdrawal, decreased interest in previous activities, loss of empathy, compulsive or obsessive behaviors, socially unacceptable behaviors.
Alzeihmers probable criteria
Normal dementia criteria and
Insidious onset
Clear cut history of worsening cognition by report or observation
IINitial and most prominnet cognitive deficiets are evident on histories and exma in one of
-amnestic presentation
-Nonamnestic presentation
Amnestic presentation of AD
It is the most common syndromic presentation of AD dementia. The deficits should include impairment in learning and recall of recently learned information. There should also be evidence of cognitive dysfunction in at least one other cognitive domain, as defined earlier in the text.
Nonamnestic presnetations of AD
Language
Visuospatial
Executive dysfucntion - judgement, reasoning etc
INdiciative biomarkers of aleihmers
Tau, amyloid beta
Core clinical features of DLB
Fluctuating cognition - pronounced variation in attention and alertness
Recurrent visual hallucinations detailed
REM sleep behaviour disorder
One or more spontaneous cardinal features of parkinsons
Investigations for indicative biomarkers of DLB
Reduced dopamine tranporter uptake in absal ganglia on SPECT or PET
Abnormal iodine - MIBG myocardial scintigraphy
Polysomnograohic confrimation of REM sleep without atonai
When can DLB be probable?
Twp or more clinical features of DLB present with or wothout presence of indicative biomarkers
ONly one core clincial feature with one or more clinical biomarkers
What is possible DLB>
Once clinical feature, no + biomarkers
1 indicative biomarkers but no clinical features
WHen should DLB be diagnosied>
When dementia occurs before or concurrently with parkinsonism
What is PDD?
Parkinsons disease dementia - when demnetia occurs in context of well established Parkinsons disease
How long before DLB becomes PDD?
1 year after onset of parkinsons symptoms
What is used to diagnose global impairment DLB?
Mini - mental state examination - MMSE
Montreal cognitive Assessment
Pattern of vascular dementia course
Static
Remitting
Progressive
Subtypes of vascular dementia
ischemic and hemorrhagic strokes, cerebral hypoxic-ischemic events, and senile leukoencephalopathic lesions;
What do you need to establish for diagnosis of vascular dementia?
Relationship between stroke and dementia
Further tests for alzeihmers after CT
FDG-PET scan
Perfusion SPECT
OR
examine CSF for:
Total tau and phosphorylated tau
Amyloid beta 1-40 or 1-42
What can make you get a false posotive on CSSF with AD?
bEING OLDER
Further tests for dementia with lewy bodies after CT
I-FP-CIT SPECT
if unavailanle use I-MIBG cardiac scintigrapgy
Further tests for FLTD
FDG PET OR perfusion SPECT
Don’t rule out based on any imaging tests
Further tests for vascular dementia
MRI/CT
Hwo to differentiate delirum and dementia with cognitive impairement in hisptial?
Long confusionassessment method (CAM)
Observational Scale of arousal - OSLA
What need to be aware of when managing dementia
arrange an initial assessment of the person’s needs, which should be face to face if possible
provide information about available services and how to access them
involve the person’s family members or carers (as appropriate) in support and decision-making
give special consideration to the views of people who do not have capacity to make decisions about their care, in line with the principles of the Mental Capacity Act 2005
ensure that people are aware of their rights to and the availability of local advocacy services, and if appropriate to the immediate situation an independent mental capacity advocate
develop a care and support plan, and:
agree and review it with the involvement of the person, their family members or carers (as appropriate) and relevant professionals
specify in the plan when and how often it will be reviewed
evaluate and record progress towards the objectives at each review
ensure it covers the management of any comorbidities
provide a copy of the plan to the person and their family members or carers (as appropriate).
Interventions to promote wellbeing cognitiona nd independece in dementia
Cognitiove stimulation group therapy
Group reminsicence therapy
Cognitive rehabilitation or OT
What are recommended as pharmacological treatments in Alzeihmers disease? mild or moderate
ACE inhibitors - donepezil, galantamine, rivastigmine
Consider memantine - moderate
Who do you offer memantine to?
Moderate alzeihmers disease who are intolerant or contraindicated for ACEis OR
severe alzeihmers
What limitations are there for cognition scores?
Learning disability
Not in first language/ not sutiably fluent to assess for dementia
When give galantamine?
Mild to moderate dementia with Lewy bodues if donepezil and rivastigmine not tolerated
When consider ACEis or memantine in vascular dementia?
Comorbid alzeihmers, parkinsons disease or DLB
What tyoe of dementia can;t be medicated?
Frontotemproal dementia
What causes logopenic demenita
Lazeihmers disease Used to think FLTD
What to assess about medications when someone is diagnosed with dementia?
Anticholinergic burden of different medications and whether can swap to something with less - look at ACh cognitive bruden scale
What need to assess for peope with dementia after history?
Medication
Distress - reasons for, clincial and environmental causes
When offer antipsychotics for people living with dementia?
At risk of harming themselves or others
Experiecning agitation, hallucinations that are causing severe distress
What dementia type are antipsychotics contraindicated in?
DLB/parkinsons DD - can worsen motor features and cause severe antipsychotic sensiticuty reactions
What do when give antipsychotics in dementia
eg risperidone and haliperidol, lowest effective dose for shortest possible time
reassess at least every 6 weeks
What do when give antipsychotics in dementia
eg risperidone and haliperidol, lowest effective dose for shortest possible time
reassess at least every 6 weeks
When offer medicatin for s=depression and anxiety in dementia?
DO NOT in mild or mod depression in mild to mod dementia unless pre exisiting sever mental health condition
What think about when person with dementia may need hospital admission?
Additional harms eg:
disorientation
a longer length of stay
increased mortality
increased morbidity on discharge
delirium
the effects of being in an impersonal or institutional environment.
Take into account:
Any advance care and support plans
The value keeping them in familiar environment
Test to assess cognitive assessment in GP
6 SIT
Risk factors for delirium
Age 65 years or older
Cognitive impairment and/or dementia
Current hip fracture
Severe illness - deteriorating or at risk of
Categories of symptoms of delirium
Cognitive function
Perception eg hallucinations
Physcial function
Social behaviour
Changes seen in hypoactive delirium
Withdrawal
Slow responses
Reduced mobility and movement
Worsened concentration and reduced appetitie
Changes in cognitive function in delirium
Worsened concentration
Slow responses
Confusion
Physical function changes in delirium
Reduced mobility
Reduced movement
Restlessness
Agitation
Changes in appetite
Sleep disturbance
Social beahviour changes in delirium
Difficulty engaging with or following requests
Withdrawa;
Alterations in communication, mood and/or attitude
How long into admission assess people at risk for clinical factors contributing to delirum?
24 hours of admission
How do you adress cognitive impairment and/or disorientation by?
Appropriate lighting and clear signage
Clock - 24 hour
Calendar easily visible
Reorientate the patient - explain where they are, who they are and what your role is
Introduce cognitively stimulatinf activities
Facilitating regular visits from family and friends
How to address dehydration and/or constipation
Ensuring adequate fluid intake encourage to drink
Offer SC or IV fluids if neccessary
Take advice necessary when managing fluid balance w comorbidities eg HF or CKD
How to address dehydration and/or constipation
Ensuring adequate fluid intake encourage to drink
Offer SC or IV fluids if neccessary
Take advice necessary when managing fluid balance w comorbidities eg HF or CKD
Hypoxia assess and optimise oxygen saturation
How to adress infection in delirium?
Looking for and treating infection
Avoiding unnecessary catheterisation Implementing infection control procedures
How to assess immobility?
Encourage mobilisation after surgery
Walk - walking aids etc
Ecourage all people incl those unable to walk, carry out active range of motion exercises
How to address pain in delirium?
Assess for pain, look for non verbal signs of pain esp those w communication difficulties - learning difficulties or dementia, people on ventilator or tracheotomy
Start and review appropriate pain management in any person pain is identified or suspecetd
Sensory impairment deal with how
Reversible causes resolve eg ear syringe for ear wac
Ensure good hearing and visual aids are available to use and in good working order
Sensory impairment deal with how
Reversible causes resolve eg ear syringe for ear wac
Ensure good hearing and visual aids are available to use and in good working order
What to do if indicators for delirium identified? What is differnet in critical care?
4AT assessment
In critical care or recovery room after surgery use Confusion assessment mthod for ICU (CAM-ICU) ir intensice care delirium screening checklist (ICDSC)
Management of delirum
Underlying problem
Communication and reorientation
Involve friends and fmaily/carers
Provice suitable care environemnt
Whn consider short term haloperidol use in delirium?
1 week haloperidol or less at lowest dose when distressed, considered a risk to themselves or others and verbal and non berbal descalation ineffective or innapropriate
Risk of haloperisodl in delrium which conditions dangerous in
Parkinsons disease or LBD
Cardiac and neurological side effects
Infomration to give family on delirium
Inform that common and temprorary
Describe personal experience of delirium
Encourgae people at risk and their families and or/carers to tell their healthcare team about sudden changes or fluctuations in behaciour
Encourage patient to share expereicnce in recovery
What is hyperactive delirium
Subtupe of delrium characterised by heightened arousal and can be restless, agitated or agressive
What is hypoactive delirium?
Subtype of delirium caharacterised by people who become withdrawn, quiet and sleepy
Special considerations in presnetations and management in old age psychiatry
multiple illnesses & significant disability. greater medical complexity & Vulnerability.
May suffer major cognitive, affective and functional problems.
illness presentations maybe atypical.
often socially isolated.
vulnerable to iatrogenic health problems.
increased sensitivity to medication.
Requires particular attention to assessment, treatment and discharge planning.
Organic mental disorders in old age
Dementia
Delirium
Substance misuse
Organic mental disorders in old age
Dementia
Delirium
Substance misuse
Functional mental disorders in old age
Depressive disorder
Mania/BPAD
Late onset psychosis
Anxiety disorders
Personality disorders
What is the most common mental health problem in later life?
Depression
Physical risk factors for depression
Sensory impairment
Reduced mobility
Impaired ADL + social function
Chronic and disabling and treatment for physical health problems (steroids)
eg MI, hypothyroidism, Parkinsons disease, Rheumatoid arthritis
Psychosocial risk factors for depression
Social isolation
Loneliness
Lack of social support
Financial hardship
Role change
Bereavement
Loss of independence
Age related changes risk factors for depression
Changes in endocrine
Cardiovascular and inflammatory systems
Normal ageing process and changes to sleep (insomnia)
Sleep disturbance
Other risk factors for depression
Risk history of depression
Presence of subthreshold depression
FH of depression
Female
Symptoms of a depressive episode
Period of depressed mood
Diminished interest in activites = anhedonia
Activity related symptoms from depression
Changes in appetite
Changes in sleep
Reduced energy or fatigue
Cognition symptoms in depressive episode
Difficulty concentrating
Recurrent thoughts of death or suicide
Psychomotor agitiation or retardation
Emotive symptoms of a depressive episode
Feelings of worthlessness
Excessive or innapropriate guilt
Hopelessness
Time course of a depressive episode
Occuring most of the day
Nearly every day
During a period lasting at least 2 weeks
More common presentations in older adults
Report physical symptoms
Apathy and poor motivation
Psychological symptoms are more frequent
Irritability and agitation
Psychomotor retardation and risk of self neglect
Psychotic features
Psychotic features
Cognitive deficits
Physical symptoms of depression in older people
pain, dizzy, weakness, constipation
Psychological symptoms older people depression
Guilt, anxiety, suicidal ideation
Risk factor for suicide
What is nihilistic delusion?
Hallucinations and delusions in depression - psychotic features
What is pseudodementia?
Cognitive deficits are characteristic in older peoples depression
How can depressive symptoms have a relationship with dementia?
Often occur in patients with dementia
Maybe a reaction to early cognitive
Can impair cognitive function - pseudodementia, difficulties in concentration and memory
Maybe risk factor for developing dementia
Ass risk factors for suicide
Male
Old
Living alone, social isolation
Bereavement
Poor physical health
Psych illness and alcohol misuse
Recent discharge from general hospital
high rates of contact primary care
Recent life events
Prev self harm
Ass risk factors for suicide
Male
Old
Living alone, social isolation
Bereavement
Poor physical health
Psych illness and alcohol misuse
Recent discharge from general hospital
high rates of contact primary care
Recent life events
Prev self harm
What to assess risk for in older people with mental heath probelms?
Self neglect
Physical health decline
Psychosis
Suicide
Self harm
Indiciations for ECT
Psychomotor retardation
Severe depression
What medications can cause hyponatremia related to mental health?
SSRI and hyponatremia
What does a new episode of bipolar affective disorder in an older adult suggest?
Suspicion of an underlying physical cause for the symptoms espiecially if no histroy of brain disorder eg brain damage, hyperthyroidism, temporal lobe epilepsy
What can present as bipolar affective disorder in older people?
brain disorder eg brain damage, hyperthyroidism, temporal lobe epilepsy
Common causes of late onset schizophrenia in elderly
Long-standing psychotic illness
Mood disorder
Dementia
Very late onset schizophrenia
Risk factors of late onset schizophrenia?
Female
Social isolation
Sensory impairments (sight, hearing)
Associations iwth late onset schizophrenia
History of poor adjustment & unusual personality / Schizoid personality traits
Schizoid personality traits
paranoia, lack of interest in social relationships, secretiveness, restricted expression of emotions
Clinical features of late onset schizophrenia
Persecutory delusions and auditory hallucinations
Less commonly:
Thought disorder
Negative symptoms eg deficits in emotional response and motivation or catatonia
What differentials consider when experience visual hallucinations?
Delirium
Lewy Body dementia
Anti-Parkinsonian drugs
Charles Bonnet syndrome
What is charles bonnet syndrome?
Visual hallucinations as a result of sight loss
What is charles bonnet syndrome?
Visual hallucinations as a result of sight loss
What to consider when mananging late onset schizophrenia?
Exclude organic causes - physical, meds side effect, dementia
Use of antipsychotic medication, lower dose and physical health monitoring
Treatment of other ass conditions
Review sensory deficits and adress social isolation
Consider psychological approaches
Carer assessment, social services, role of GP, community psychiatrist, voluntary/3rd sector services
What need to monitor in antipsychotics physically?
BP, pulse rate, weight, blood glucose, ECG, EPSE
Common physical causes of anxiety in older people
Heart diseases - MI, arrhythmias, lung diseases (COPD, pneumonia), hyperthyroidism
What differentials for new onset primary anxiety disorder in old age?
Dementia, depression, physical
WHat is the main treatment for anxiety disorders?
CBT commonly used
When prescribe SSRIs for anxiety when your old?
Co-exisitng mood sympomts
Prevalence of personality disorders in older adults
10%
Psychological interventions for personality disorders
as supportive psychotherapy, CBT, cognitive analytic therapy, psychodynamic therapy & family the
sleep changes elderly
less sleep
wake early
toilet in night more
