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
