Dementia/delirium Flashcards
PATIENT PRESENTS WITH CONFUSION TO A&E
i) name a tool that can be used to assess? what do you want to distinguish between?
ii) name six things that can cause acute delirum? name three non medical causes
iii) what type of history may be important?
i) use AMTS
- need to distinguish between acute change and long term cognitive impairment
ii) fall, infection, electrolyte imbalance, metabolic (hypo), urine retention/constipation, hypoxia
iii) collateral - get is ASAP
ASSESSING CONFUSION
i) what is squid?
ii) name three other criteria that can be used to assess
i) single question in delirium - is this patient more confused than they usually are?
ii) AMTS - orientated to time, person, palce
CAM (confusion asessment method) - four criteria - need 3 of them for dx of delerium
MMSE
INVESTIGATIONS TO ORDER IN CONFUSION
i) name six investigations and what would be looked for in each? what are you looking for?
i) look for a reversible cause
- FBC - infection/anaemia
U&E - baseline, electrolyte disturbance
LFT - baseline
CRP - infection/inflammation
Cultures - infection
ECG - arrhythmia, ischaemia
COLLATERAL HISTORY
i) what does MAPLEV stand for? what is assessed in each section?
ii) how many of these domains are affected in dementia?
i) Memory and learning - acute/chronic change, duration
Attention - ability to focus on tasks
Personality - change inc mood/behaviour
Language - difficulty understanding/communicating
Executive func - ability to plan/perform complex tasks eg driving, dressing, cooking
Visuospatial perception - changes in recog objects or hand eye co-ord
ii) more than 2 affected in dementia
DELIRIUM
i) name causes using DELIRIUM
ii) what is hyperactive delirium?
iii) what is hypoactive?
i) Drugs (withdraw/tox) or Dehydration
Environment/energy
Level of pain
Infection/inflamm post surgery
Resp failure (hypox, hypercap)
Impaction of faeces
Urinary retention
Metabolic disorders - liver/renal fil, thyroid, hypogly
ii) hyperactive = heightened arousal, restless, distressed
iii) hypoactive = withdrawn, sleepy, quiet
(can also be mixed)
TREATMENT OF DELIRIUM
i) what should be repeated to the patient? name four non pharma tx
ii) when is the only time pharma tx is used? what pharma agent is given first line?
iii) what is given second line? which two conditions should this be avoided in?
iv) which route of admin is never used?
i) keep reminding them where they are
- prevention, tx underlying cause, correct enviro, communicate and re-orientate
ii) only use pharma tx as a last resort - always try to reorientate first
- lorazepam is given first line (benzo)
iii) second line > haloperidol (avoid with PD/DWLB)
iv) never give IV - only PO or IM
DEMENTIA DIAGNOSIS
i) how does the ICD-10 define it? what is it accompanied by?
ii) what are the top four most common types of dementia in order?
iii) is it more common in men or women?
i) syndrome due to disease of the brain, chronic/progressive in nature where there is impair of more than one cog domain (memory, language, fluency, exec func, vis spat, percep, social cog)
- accompanied by impairment of function
ii) 1) alzheimers, 2) vascular, 3) FTD, 4) dementia w lewy bodies
iii) more common in women
TYPES OF DEMENTIA
explain
i) alzheimers? which NT is reduced?
ii) vascular
iii) FTD
iv) DWLB
i) AD > gradual onset of impaired memory, planning and func skills due to degen of ceb cortex, cortical atrophy, NF tangles, amyloid plaques and reduc in Ach
ii) vascular > due to cebvasc disease (1 large stroke or multi infarcts), stepwise decline that px similar to AD but initially pts have more insight
iii) FTD > changes in personality (disinhib)m behaviour, difficulty with language - usually dev at younger age eg 60yrs
iv) DWLB > triad of cog fluctuation, vivid visual hallucinations and parkinsonism
COGNITIVE ASSESSMENT IN DEMENTIA
i) what is cognition? (3) which scoring system may be used? below what score is dementia
ii) what is attention? name three ways this can be assessed
iii) what is executive function? name two ways it can be assessed? what test can assess it
iv) name three ways language can be assessed?
v) name two ways fluency can be assessed?
vi) how can visuospatial ability be tested?
i) correctly interpreting input from sensory organs, appropriate judhement and ability to initiate verbal/motor response
- can use addenbrookes cognitive examination - below 82
ii) ability to choose and concentration on relevant stimuli
- what is the day, where are we, repeat words, subtract 7s
iii) behavioural regulation and decision making processes
- ask how to make cup of tea/how they got here
- ask how finances/shopping are being managed
- stroop test
iii) write sentences about last weekend, repeat complex words, name pictures
iv) how many words with C/animals can you name in 60 seconds?
vi) copy diagram/drawing, usually shapes
IMAGING IN DEMENTIA
i) what is seen on CT head in AD?
ii) which imaging technique is most sensitive in VD? what is seen? (2) whats scoring system is used in vasc dementia?
iii) name two things seen on MRI in DWLB? what other type of imaging is useful? what is seen
iv) what is seen on MRI in FTD? (3)
i) medial temporal lobe atrophy/temproparietal cortical atrophy
ii) MRI > see white matter small vessel ischaemic change (hyperintensities) > use fazekas score (level of white matter change)
iii) MRI > generalised decreased ceb volume and enlargement of lateral ventricles
- also do DAT scan (dopamine imaging)- see decreased DA uptake
iv) frontal and temporal atrophy, assymetric, with caudate head volume loss, widening sulci
ASSESSMENT OF DEMENTIA
for AD, VD, DWLB, FTD
i) which imaging
ii) how quickly does disease progress
iii) name four cognitive domains involved
iv) what do all have in common?
i) AD = CT/MRI, gradual/progressive, involves episodic memory, language, fluency, exec func, complex attention
VD = CT/MRI, step wise progression, invovles semantic memory, lang, fluency, exec func, complex atten, visuospatial
DWLB = DAT scan, progressive decline with cognitive fluctuation, involves perceptual, visspat, attentional, executive
FTD = CT/MRI, progression is gradual, progressive or variable, involves social cog, exec func, attention, language
iv) all have impairment of function
TREATMENT OF DEMENTIA
i) what is the most important thing?
ii) name three psych therapies? three social therapies?
iii) what is the aim if biol therapies? what is given in mild/mod AD?
iv) what biol therapy can be given in severe AD? what type of drug is it?
v) what needs to be assessed in VD? what can then be done?
i) supportive tx is the most important thing (social support)
ii) psych - cog stimulation therapy, group reminiscence therapy, behav support planning
- social - respite placements, adult social care, attendance allowance, adv care planning
iii) biol therapies aim to slow process of cog impair (not reverse it)
- mild.mod AD > give donepezil, galantamine (Ach esterase inhibitors)
iv) severe AD - NMDA receptor antagonist = memantine
v) VD = address vasc RFs eg diet, smoking, BP > give aspirin, anti hypertensives and statins
