Dementia / Delirium Flashcards
Gist of the DSM-5 criteria for delirium
Acute and fluctuating syndrome of impaired attention and awareness
Most useful bedside assessment tool for delirium and how often should be used
Confusion Assessment Method (CAM)
Screen at least daily if at risk
Elements of CAM
- acute change in mental status and fluctuating course
- Inattention ( one of following: digit span, days, months, continuous performance task, serial 7s, “world” backward)
- Disorganized thinking (rambling, unclear, flitting btwn subjects)
- Altered LOC (anything other than alert – vigilant, lethargic, stuporous, comatose)
1, 2, and either 3 or 4
Predisposing factors for delirium
Advanced age, dementia, prior delirium, dependency in ADLs, medical comorbidities, history etoh use, male, diminished vision/hearing
Precipitating causes for delirium
- Drugs
- Electrolyte distrubances
- Lack of drugs
- Infection
- Reduced sensory input or mobility
- Intracranial
- Urinary, fecal
- Myocardial, pulmonary
- Surgery
Causes are usually multifactorial, and sometimes a small insult can push a person over the edge
Medications that can contribute to delirium
anythin - even tylenol, antibiotics! Common offendors:
Alcohol, anticholinergics (oxybutynin, benztropine), anticonvulsants (primidone, phenobarbital, phenytoin), antiDs (amitriptyline, imipramine, doxepin), antihistamines (diphenhydramine), anti-inflammatory agents (prednisone), antiparkinsonian agents (levodopa-carbidopa, dopamine agonists, amantadine), antipsychotics, barbiturates, benzodiazepines (triazolam, alprazolam, diazepam, flurazepam, chlordiazepoxide), H2 agonists (cimetidine, ranitidine), opioid analgesics (especially meperidine)
Lab tests you may order for delirium based on H & P
- CBC, TFT, serum drug levels, CXR, CMP, UA, arterial blood gases, ECG, serum calcium, blood cultures, ammonia, blood alcohol levels
- *cerebral imaging rarely helpful unless head trauma or new focal neuro findings.
- EEG and CSF rarely helpful unless seizure activity or signs meningitis
Prevention/mgmt. strategies for delirium
- ID and reverse contributors
- Maintain behavioral control (appropriate interactions, family visits)
- Anticipate and prevent or manage complications (urinary incontinence, falls, ulcers, sleep, feeding Dos, …)
- Restore function in delirious patients
Pharm mgmt for agitated delirium
- If behavior is dangerous to patient or others and other interventions do not work
- *Do not newly Rx cholinesterase inhibitors to prevent/tx delirium
- *Do not use antipsychotics as prophylaxis
- Agent of choice is typically haloperidol
Possible warning signs of dementia
Unkempt appearance, poor historian, difficulty following instructions, repeating the same question, lost in familiar places
Examples of screening instruments for evaluation of cognition
Mini-cog, SLUMS, MoCA, Folstein MMSE
Characteristics of normal aging
- Mild decline in memory
- More effort/time needed to recall new info
- New learning slowed but well compensated by lists, calendars, etc
- No impairment in social and occupational functioning
Characteristics of mild cognitive impairment
- Subjective complaint of cognitive decline in at least one domain: memory, executive function, language, or visuospatial perception
- Cognitive decline is noticeable and measurable
- No impairment in social and occupational functioning
Characteristics of Alzheimer’s dementia (DSM IV diagnostic criteria)
- Memory impairment &
- Aphasia OR apraxia or agnosia OR disturbed executive functioning &
- Causes significant impairment in social and occupational functioning and represents a significant decline from previous level of functioning
- Other medical and psychiatric conditions, including delirium, have been excluded
Alzheimer’s vs vascular vs Lewy body vs frontotemporal
Onset
Gradual: alz, LBD, FTD (<60)
Sudden or stepwise: vascular
Alzheimer’s vs vascular vs Lewy body vs frontotemporal
Cognitive domains and symptoms
- Alz: memory, language, visuospatial
- VD: depends on location
- LBD: memory, visuospatial, hallucination, fluctuating sx
- FTD: executive dysfunction, personality changes, disinhibition, language, +/- memory
Alzheimer’s vs vascular vs Lewy body vs frontotemporal
Motor sx
- Alz: rare early, apraxia later
- VD: correlates w/ischemia
- LBD: parkinsonism
- FTD: none
Alzheimer’s vs vascular vs Lewy body vs frontotemporal
progression
- Gradual but alzheimer’s takes longest
- VD may be stepwise
Alzheimer’s vs vascular vs Lewy body vs frontotemporal
Imaging
- AD & LBD: possible global atrophy
- VD: cortical or subcortical changes on MRI
- FTD: atrophy in frontal and temporal lobes
(possible) risk factors for alzheimer’s
Advancing age, hx head trauma, late onset MDD, fewer years formal education, RFs for CVD
Primary treatment goals for pts w/dementia
- Enhance QoL and maximinze functional performance
- improve/stabilize cognition, mood, behavior
recognize that there are no good treatments - that’s why screening is not recommended for (or against) by USPSTF
MGMT strategies for dementia
Info for pt/caregiver
- diagnosis, prognosis, behavioral symptoms
- home safety
- adult day cares, respite stays
- support groups/classes for caregivers
- advance directives, surrogate decision maker
Alzheimer’s vs vascular vs Lewy body vs frontotemporal
Treatment
- Cholinesterase inhibitors
- AD: modest benefits
- VD: not recommended.
- Discuss initiation of stroke propylaxis meds
- LBD: may help manage attention and behavioral disturbances
- FTD: no role! May worsen agitation
*need to have realistic expectations
Evaluate after 6mo
Taper off!
Referrals for dementia
- Driving assessment
- Full neuropsychological testing, esp if atypical or when presentation confounded by high level of education or subtle changes
ADLs
bathing, eating, dressing, transferring, toileting
losing these = losing function
IADL
- Managing finances, handling transportation, shopping , preparing meals, telephone, managing meds, housework
- First to go: pay bills – notice a loved one has not been paying bills
Sleep problems/hallucinations then parkinson’s movement symptoms. What do you suspect?
Lewy Body
If mvmt first - likely parkinson’s
