Dementia/delirium Flashcards
What is cognitive impairment?
Disturbance of higher cortical functions,
including memory, thinking, judgement, language, perception and awareness
Cognitive impairments may be single or multiple and may be static or progressive
It is not a specific illness but description of someones condition
What is dementia?
Cognitive impairement with decline in both memory and thinking which is sufficient enough to impair personal activities of daily living
Problems with the processing of incoming information (problems with maintaining and directing information)
CLEAR CONSCIOUSNESS
Above syndrome will be present for more than or equal to 6 months
What is delirium?
Impairement of cognition- disturbances of attention and conscious level; abnormal psychomotornbehaviour and affect, disturbed sleep- wake cycle
Onset is usually acute (hours/days)
All symptoms fluctuate during the daytime and are typically worse at night
2 SUBTYPES- hyperactive and hypoactive (easily overlooked 😟)
Hypoactive is the most common type
What does the inverse care law mean?
In someone with dementia, the more their disease progresses they become more dependent and vulnerable but also become less aware of their disabilities
What causes dementia?
Dementia is a syndrome, a range of diseases may cause it…
- alzheimers disease
- vascular dementia
- alcoholic
- dementia with lewy bodies
- frontotemporal dementia
- huntingtons disease
What are the early stage features of dementia?
Forgetfulness and other memory symptoms (most prominent cognitive abnormality, especially in Alzheimers disease)
There may be subtle changes in mood and behaviour- loss of motivation and interest
There may be minimal intrusion into day to day functions at the start ie: financial
What are the mid stage features of dementia?
Memory problems become more prominent and other cognitive difficulties may start to emerge
Behaviour becomes more marked
Disability becomes more obvious and they will need frequent support but not continous support and assistance
Often their awareness of disability starts to diverge from reality
What features are in the late stage of dementia?
Severe and pervasive memory problems accompany other major cognitive disabilities- severe disorientation, failure to recognise familiar people
Marked (+ve and -ve) changes in behaviour- agitation, restlessness, irritability, disinhibition, severe apathy
Disability is severe and even basic aspects of personal functioning snd failing, people require more or less continous supervision
What are the differentials for dementia?
hypothyroidism, Addison's B12/folate/thiamine deficiency syphilis brain tumour normal pressure hydrocephalus subdural haematoma depression chronic drug use e.g. Alcohol, barbiturates
What is vascular dementia?
Vascular dementia (VD) is the second most common form of dementia after Alzheimer disease. It is not a single disease but a group of syndromes of cognitive impairment caused by different mechanisms causing ischaemia or haemorrhage secondary to cerebrovascular disease. Vascular dementia has been increasingly recognised as the most severe form of the spectrum of deficits encompassed by the term vascular cognitive impairment (VCI). Early detection and an accurate diagnosis are important in the prevention of vascular dementia.
What are the risk factors of vascular dementia?
History of stroke or transient ischaemic attack (TIA) Atrial fibrillation Hypertension Diabetes mellitus Hyperlipidaemia Smoking Obesity Coronary heart disease A family history of stroke or cardiovascular
What do patients with vascular dementia present with?
Several months or several years of a history of a sudden or stepwise deterioration of cognitive function
Symptoms and speed of progression vary, but may include..
- focal neurological abnormalities (visual disturbance, sensory or motor symptoms)
- difficulty with attention and concentration
- seizures
- memory disturbance
- gait disturbance
- speech disturbance
- emotional disturbance
What may you see on an MRI of someone with vascular dementia?
May show infarcts and extensive white matter changes
What are the features of lewy body dementia?
In contrast to Alzheimers, early impairements in attention and executive function rather than just memory loss
Cognition may be fluctuating, in contrast to other forms of dementia
Usually develops before parkinsonism
Parkinsonism
Visual hallucinations (delusions and non visual hallucinations may also be seen)
How do you assess a patient with suspected dementia, in terms of history and examination…
Diagnostic assesment is a 2 stage process…
Firstly you diagnose the syndrome and then you diagnose the disease
History…
What is the course of the symptoms over time?
This is the most important bit of diagnostic information and the patient probably won’t be able to tell you
Is there any evidence of disability or impact on the day to day life?
Why have they come now? Has anything happened recently?
Any changes in the general health?
Examination
Cognitive screening assessment- GPCOG, AMT, 6-CIT, MMSE, MOCA etc….
Check for new physical findings if prompted by hx
(Neurological or cardiovascular)
What investigation do you do for suspected dementia?
‘Dementia screen’ bloods (these are not actually screening for dementia but screening for other things that may be contributing to the dementia)
FBC, LFTS
Structural brain imaging- CT/ MRI
Functional brain imaging- perfusion, glucose metabolism, dopamine transporter turnover (not routinely done)
Specialised tests for special situations with unusual disease like prion disease (EEG, lumbar puncture)
How do you manage dementia?
For all patients- give information and explanation
Give psychological support- maintaining a positive outlook and remaining engaged in life
Practical advice to cope with cognitive problems +/- assistive technologies
Carer support
For some types of dementia there are drug treatments
What drugs can be given to patients with alzheimers disease?
Cholinesterase inhibitors
Donepezil, rivastigmine, galantamine
NDMA receptor antagonists
Memantine
What can you give for parkinsons disease dementia/ DLB?
Rivastigmine
How does memantine work?
Predicated on the glutamate overactivity hypothesis in AD
Blocks NDMA receptors which glutamate usually bind tl
What drugs should you avoid in patients with dementia?
Avoid anticholinergics- these can cause cognitive deterioration, hallucinations and other psychotic symptoms
Benzodiazepines- use sparingly due to the risk of falls, cognitive decline etc
Antipsychotic tranquilisers- avoid where possible due to risks of stroke, falls, movement disorders and cognitive deterioration
What are the risk factors for delirium?
Pre existing cognitive impairment Fracture on admission Age over 80 Illness severity Age over 65 Infection Vision impairment
What drugs can induce delirium?
Psychiatric drugs- antidepressants, antipsychotics, benzos
Anti parkinsonian
Anticholinergic
Opiates
Diuretics
Recreational drug intoxication and withdrawal
Give examples of drugs with anticholinergic properties which can cause delirium in older patients…
Antihistamine- hydroxyzine, diphenyhdramine Antisasmodic- alverine, hyoscyamine TCAs- Amitriptyline Lorazepam Codeine Anti arrthymic- digoxin Diuretic- furosemide Antiparkinsonian Bladder stabliser- oxybutnin Bronchodilator- theophylline
What screening tools can be used in delirium?
CAM score
THINK delirium
What is the immediate actions when you think someone has delirium?
Focused history and examination
Collateral history (GPs/relatives/carers)
Identify and treat the underlying causes
Refer to UHL sepsis if suspecting sepsis
Complete the ‘know me better’ profile with carers
Cognitive assessment with AMT 10/ MMSE
Perform medication review using STOPP/START
Heighten the patients level of supervision and position patient in a high visibility bed if available
Update and involve relatives and carers with provide UHL delirium leaflet
Refer to FOPAL for complex and challenging patients only (frail older persons advice and liaison)
What does THINKDELIRIUM stand for?
T= trauma (head injury, intracranial event) H= hypoxia (PE, CCF, MI, COPD, pneumonia) I= increasing age/frailty N= neck of femur fracture K= smoKer (or alcohol withdrawal) D= drugs E= environment (movement on different wards) L= lack of sleep I= imabalanced e-s (renal failure, Na+, Ca2+, glucose, liver function) R= retention (urinary or constipation) I= infection/sepsis U= uncontrolled pain M= medical conditions like dementia and parkinsons disease
How do you treat delirium?
Treat the underlying cause and exacerbating factors
Provide personalised care
Manage pain (may not be able to tell you, look for winching)
Rationalise meds
Re orientate pts
Ensure the environment is well lit and minimise excessive stimulus where possible
Involve family and carers where appropriate
Ensure patients have earing aids, contact lenses
Encourage oral intake
Communicate clearly to patients- reassure and repeat
Enable good sleep
Manage constipation
Mobilise the patient
What are the key features of delirium?
Acute onset Fluctuates Altered level of consciousness Cognitive decline Inattention Behavioural and psychological disturbances Hypo or hyperactive
What are the most common MH problems in older adults in hospital?
The 3Ds
Dementia, delirium, depression
Why is delirium improtant?
Delirium is associated with poorer patient outcomes…
- increased length of stay in hospital
- increased mortality rates
- increased hospital re admissions
- increased chance of needing 24hr care on discharge
- higher correlation between people who suffer delirium who go on to develop dementia
How can you assess a patient with delirium?
Clarify the patients baselines- a patient hx/ collateral is one of the most important tools
You need to check for reversible causes
Complete bloods- U and Es, FBC, LFT, calcium, glucose, CRP
Check bowels (constipation)
Physical observations (temp, signs of infection, O2 sats in an acceptable range?)
Mid stream urine sample
Review the patients drug history- have any meds been stopped or started ?
CT head to rule out potential acute intracranial changes
Others guided by hx CXR, lumbar puncture, MRI, EEG (seizures/ encephalitis), ABG
What are the important delirium screening tools?
SQiD
Single question in delirium, this is what it says on the tin, it is basically when you ask someone that knows the patient whether they have been more confused in the past 3 days
Confusion assessment method
4 questions
Is there an acute onset with fluctuating course
Is the patient inattentive
Is there evidence of disorganised thinking
Are there altered levels of consciousness?
4AT
(4 or more= delirium present)
6CIT (much quicker delirium screening), higher the score the worse the patient
Longer like the MOCA, MMSE, or ACE not appropriate as they take too long
What pharmacological management can be given to delirium?
Haloperidol 0.5-1 mg in elderly aim for a max of 2mg in 24hrs
However do not use haloperidol in patients with a background of parkinsons or lewy body dementia
Therefore you can give lorazepam (0.5-1mg)
Why should you not give antipsychotics with haloperidol?
There is a risk of QTc prolongation!
What are hyperactive and hypoactive often misdiagnosed as?
Hyperactive- acute psychosis
Hypoactive- depression
What are the shared/ opposing features of delirium or depression?
Delirium- perceptual disorder, FLUCtUATING, clouding consciousness, disordered attention
Depression- pervasive unhappiness, anhedonia, negative thought content, suicidal thoughts
Both- anergia, reduced motivation, reduced activity levels, impaired oral intake, abnormal sleep
What is a memory clinic/service?
Defined as a MDT that assesses and diagnoses dementia, and may provide psychosocial interventions for dementia
Why is early diagnosis of dementia important?
Allows medical management to be optimised
Risk reduction
Allows access to care and services
Relief gained by knowing there is something going on, reduces blame and impatience
Maximises the patients decision making while they still have capacity
How can you break the diagnosis of dementia well?
Involve family Prepare Explore the patients perspective Disclosure of diagnosis Responding to patients reaction Focus on QoL Future planning Effective communicaton
What are two tools useful for identifying delirium?
CAM
4AT
