Dementia / delirium / confusion / capacity Flashcards
List some consequences of delirium if left un-recognised and un-treated
- 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
State the 4 topics to cover in the AMT-4 assessment for confusion
DOB
Age
Place
Year
List key modifiable risk factors for the development of Alzheimer’s / dementia
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
List some predisposing factors that make a patient more at risk of developing delirium
- 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
List some risk factors for someone developing delirium (THINK DELIRIUM)
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
List 4 parameters assessed in the confusion assessment method (CAM)
Acute onset with fluctuations
Inattention
Disorganised thinking
Altered level of consciousness
List some presenting features for delirium
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- Withdrawn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
Outline how to manage a patient with delirium
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)
State the first line antipsychotic to use in delirium (if absoloutely needed after de-escalation techniques etc.)
Haloperidol (unless if Parkinson’s disease, then Lorazepam)
List some domains which dementia affects e.g. memory
- Learning and memory
- Executive function
- Motor ability
- Language
- Social cognition
- Complex attention
= affects independent function of activities of daily living
State the leading risk factor for dementia
Increasing age
List some risk factors for dementia
Non-modifiable:
- Increasing age
- Early life depression
Modifiable:
- Smoking
- Excessive alcohol
- CVS risk factors e.g. HTN, hypercholesterolaemia
- Diabetes
- Obesity
- CHF
- Atrial fibrillation
- OSA
List 2 protective factors against the development of dementia
- More years of formal education
- Social engagement and cognitive stimulation activities e.g. puzzles
List some presenting symptoms of dementia
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
Outline some features of middle and later stages of dementia
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
List some behavioural and psychological changes in dementia (BPSD)
- Personality change
- Agitation / aggression
- Anxiety
- Sleep disturbance
- Psychosis
Outline how the behavioural and psychological changes in dementia can be managed
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
Outline the difference between dementia and mild cognitive impairment
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
List some benefits of early dementia diagnosis
- 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!
List some things that the memory clinic does in the care of dementia patients
- 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
List some standardised assessment tools for dementia
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
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
Normal = > 26
Mild = 21-26
Moderate - moderately severe = 10-20
Severe = < 10
List some limitations of cognitive status assessments for dementia
- Insensitive to preexisting cognitive deficits
- Not incorporating learning issues
- Not incorporating sensory impairment e.g hearing issues
- Difficulties if English as second language
List some investigations that can be undertaken in memory clinic for someone presenting with suspected dementia
- 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
