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Year 4 - 6. OPIC > Dementia / delirium / confusion / capacity > Flashcards

Dementia / delirium / confusion / capacity Flashcards

1
Q

List some consequences of delirium if left un-recognised and un-treated

A
  • Increased hospital stay / nursing care
  • Risk of cognitive / functional decline
  • Delayed rehabilitation / post-op recovery
  • Distress to caregivers
  • Distressing in terminally ill patients (psychosocial closure)
  • Risk of mortality for up to 2 years after
  • Risk of readmission or institutionalisation
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2
Q

State the 4 topics to cover in the AMT-4 assessment for confusion

A

DOB
Age
Place
Year

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3
Q

List key modifiable risk factors for the development of Alzheimer’s / dementia

A

Medical:
- HTN
- Diabetes
- Hearing impairment

Lifestyle:
- Smoking
- Obesity
- Physical inactivity
- Excessive alcohol consumption

Social:
- Poor education
- Poor social contact

Other:
- Depression
- Traumatic brain injury (TBI)
- Air pollution

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4
Q

List some predisposing factors that make a patient more at risk of developing delirium

A
  • Previous delirium

Non-modifiable:
- Increased age (>65)
- Male

Modifiable:
- Alcohol abuse
- Dehydration
- Malnutrition

Medical:
- Preexisting cognitive impairment
- Poor vision / hearing
- Immobility
- Medical conditions e.g. stroke, renal or hepatic impairment, HIV, fractures or trauma, neurological disease

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5
Q

List some risk factors for someone developing delirium (THINK DELIRIUM)

A

THINK DELIRIUM

Trauma
Hypoxia
Increasing age/frailty
Neck of femur fracture
smoKing or alcohol

Drugs e.g. new/stopped
Environment
Lack of sleep
Imbalanced electrolytes (renal failure, Na, Ca, glucose, LFTs)
Retention (urinary or consitpation_
Infection / sepsis
Uncontrolled pain
Medical conditions e.g. dementia, Parkinson’s disease

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6
Q

List 4 parameters assessed in the confusion assessment method (CAM)

A

Acute onset with fluctuations
Inattention
Disorganised thinking
Altered level of consciousness

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7
Q

List some presenting features for delirium

A

Hyperative:
- High energy
- Agitation
- Pressured speech
- Restlessness

Hypoactive:
- Lack of energy
- Withdrawn
- Poor motivation

Both:
- Difficulty maintaining attention / concentration (worse in evening = sundowning)
- Reduced ability to solve problems
- Poor sleep
- Reversed sleep-wake cycle
- Hallucinations / delusions / paranoia / thought disorganisation

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8
Q

Outline how to manage a patient with delirium

A

1st line = non-pharmacological
- Modify surroundings
- Ensure visual and auditory aids used
- Involvement of family / friends + familiar items
- Close nursing
- Swap for a room with a window view
- Adequate control of pain
- Physical activity

Pharmacological:
- Antipsychotics (generally 2nd generation e.g. Aripiprazole)
- Benzodiazepines e.g. Haloperidol (unless Parkinson’s, then Lorazepam)

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9
Q

State the first line antipsychotic to use in delirium (if absoloutely needed after de-escalation techniques etc.)

A

Haloperidol (unless if Parkinson’s disease, then Lorazepam)

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10
Q

List some domains which dementia affects e.g. memory

A
  • Learning and memory
  • Executive function
  • Motor ability
  • Language
  • Social cognition
  • Complex attention

= affects independent function of activities of daily living

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11
Q

State the leading risk factor for dementia

A

Increasing age

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12
Q

List some risk factors for dementia

A

Non-modifiable:
- Increasing age
- Early life depression

Modifiable:
- Smoking
- Excessive alcohol
- CVS risk factors e.g. HTN, hypercholesterolaemia
- Diabetes
- Obesity
- CHF
- Atrial fibrillation
- OSA

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13
Q

List 2 protective factors against the development of dementia

A
  • More years of formal education
  • Social engagement and cognitive stimulation activities e.g. puzzles
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14
Q

List some presenting symptoms of dementia

A

Early stage:
- Memory loss (recent)
- Inability to learn new information
- Repetitive questions, telling of stories
- Forgetting appointments / cooking
- Losing possessions
= limited impact on ADLs

Later stages:
- Agnosia
- Apraxia (unable to perform tasks or movements when asked)
- Worsening executive functioning e.g. managing medication, finances, preparing meals
- Worsening social cognition e.g. difficulty recognising social cues, disinhibition, change in personality

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15
Q

Outline some features of middle and later stages of dementia

A

Middle:
- More prominent memory issues
- Issues with executive function & language
- Changes in behaviour
- Awareness of disease reduces
= Difficulties with complex ADLs (easy motor ADLs generally okay
= requires supervision, but not constantly

Later:
- Severe and pervasive memory problems
- Severe disorientation
- Failure to recognise familiar people
- Speech difficulties
- Marked behaviour change e.g. disinhibition, agitation, irritability
- Disability is severe
= unable to do almost all ADLs
= requires almost constant supervision

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16
Q

List some behavioural and psychological changes in dementia (BPSD)

A
  • Personality change
  • Agitation / aggression
  • Anxiety
  • Sleep disturbance
  • Psychosis
17
Q

Outline how the behavioural and psychological changes in dementia can be managed

A

1st line = non-pharmacological
- Modify environment to eliminate triggers, if possible
- Modify activities causing distress, if possible
- 1:1 supervision
- Adequate sleep, nutrition
- Stimulating activities (limit agitation)

Pharmacological options:
- Antipsychotics (generally 2nd generation e.g. Risperidone, Olanzapine)
- Benzodiazepines

Can monitor with ABC charts

18
Q

Outline the difference between dementia and mild cognitive impairment

A

Conditions affects similar parameters e.g. memory, planning, language etc.

However, mild cognitive impairment doesn’t impact ADLs and generally the family/patient isn’t too concerned

19
Q

List some benefits of early dementia diagnosis

A
  • Relief for patient/family
  • Optimise medical management
  • Access care and services
  • Allows for planning of future care, financials etc.
  • Risk reduction (mitigate risks better)
  • Cost effective!
20
Q

List some things that the memory clinic does in the care of dementia patients

A
  • Provides initial diagnosis (and subtype diagnosis)
  • Regular reviews
  • Coordinates care
  • Holistic approach to promote cognition, independence and wellbeing
  • Any pharmacological interventions
  • Manage risk e.g. driving
21
Q

List some standardised assessment tools for dementia

A

MMSE (Mini Mental State Examination)

MoCA (Montreal Cognitive Assessment)
- Out of /30
- Takes 10 mins
- Better sensitivity for early disease than MMSE

ACE3 (Addenbrooke’s Cognitive Examination)
- More detailed, out of /100
- Takes 20 mins
- Mini version of mini ACE

22
Q

List the scores associated with the following severities of dementia, as assessed by the MMSE (Mini Mental State Examination) out of 30
- Normal
- Mild
- Moderate
- Moderately severe
- Severe

A

Normal = > 26

Mild = 21-26

Moderate - moderately severe = 10-20

Severe = < 10

23
Q

List some limitations of cognitive status assessments for dementia

A
  • Insensitive to preexisting cognitive deficits
  • Not incorporating learning issues
  • Not incorporating sensory impairment e.g hearing issues
  • Difficulties if English as second language
24
Q

List some investigations that can be undertaken in memory clinic for someone presenting with suspected dementia

A
  • Routine bloods
  • ECG (most drugs can cause bradycardia)
  • CT head / MRI brain (good for determining dementia subtype)

Specific types:
- FDG (fluorodeoxyglucose) PET scan = if suspecting Alzheimers or Frontotemporal dementia
- DAT scan (dopamine scan) = if suspecting Lewy Body dementia
- MRI brain = if suspecting vascular dementia

25
Q

Outline the main management steps for dementia

A

Non-pharmacological:
- Education for patient and family
- Psychological support
- Practical advice
- Carer support
- Inform DVLA of diagnosis

Pharmacological:
- Cholinesterase inhibitors for mild/moderate Alzheimer’s
- Memantine (NMDA antagonist) for moderate/severe

26
Q

State what needs to be checked prior to starting cholinesterase inhibitors for Alzheimer’s

A

ECG = for bradycardia
Memantine (NMDA antagonist) for moderate/severe

27
Q

State what needs to be checked prior to starting Memantine (NMDA antagonist) for Alzheimer’s

A

eGFR = for renal impairment (renally excreted drug)

28
Q

Outline how the young onset dementias present differently

A

Young onset dementias:
- Memory loss is a less prominent feature
- More likely to present with motor, visual, language and behavioural symptoms earlier on
- Tend to be more physically able

29
Q

List some cognitive assessments to consider in suspected young onset dementia

A
  • Mental state examination
  • Cognitive assessments e.g. MMSE, MOCA, ACE-3, GPCOG
  • Physical examination, specially for neurological signs
    + risk assessment e.g. normal risk, but also wandering, neglect, medication compliance etc.
30
Q

List some investigations to consider for young onset dementia

A

B -
L - baseline bloods to exclude differential diagnoses
I - structural and functional MRI
P

31
Q

Suggest some management steps for a newly diagnosed patient with young onset dementia

A
  • Detailed explanation of diagnosis and prognosis

MDT referrals:
- CMHT for aftercare
- Social services
- Age UK
- DVLA / drivability
- UCL young dementias group

Pharmacology:
- Acetylcholinesterase inhibitors +/- Memantine (Alzheimer’s)
- Rivastigmine (Parkinson’s)
- Antipsychotic/ antidepressant for BPSD (use with caution)

Involvement with voluntary organisations e.g. Alzheimer’s society and young onset dementia group

32
Q

List some differentials for dementia

A
  • Delirium
  • Functional e.g. depression, anxiety, catatonia , cognitive impairment in chorionic schizophrenia
  • Substance misuse
  • Menopause
  • Fibromyalgia
  • Normal pressure hydrocephalus
  • Sensory deprivation (severe social isolation)
33
Q

List some causes of rapidly progressing dementias

A

Infection e.g. HIV, Herpes, Syphilis
Prion diseases e.g. CJD
Inflammatory conditions e.g. sarcoid, autoimmune
Metabolic e.g. heavy ,teals, vitamin deficiencies
Neurodegenerative conditons e.g. Huntington’s, mitochondrial disease
Carcinoma

34
Q

List some investigations to do for suspected rapidly progressing dementia

A

B - cognitive testing, EEG
L - bloods for toxins, autoantibodies, genetic testing
I - neuroimaging e.g. MRI
P - lumbar puncture and CSF measurement

35
Q

List the helpful mnemonic to remember the additional features for dementia

A

The ‘4As’:
- Amnesia (recent memories lost first)
- Aphasia (word-finding problems, speech muddled and disjointed)
- Agnosia (recognition problems)
- Apraxia (inability to carry out skilled tasks despite normal motor function)

36
Q

State the 2 main cognitive tests used in the GP settings

A

6-CIT = 6 item cognitive impairment test
GPCOG = better for patients who don’t know as much, uses another person who knows the patient well as an informant

37
Q

List the 5 principles of the mental capacity act

A
  1. Assume they have capacity, until proven otherwise
  2. An unwise decision doesn’t imply lack of capacity
  3. Support individual in making decisions
  4. Always consider best interest
  5. Interventions should be the least restrictive possible

Year 4 - 6. OPIC (8 decks)

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