Demetia and Delirium Flashcards
Define cognitive impairment
A disturbance of higher cortical functions
What is meant by higher cortical functions?
Memory
Thinking
Judgement
Language
Perception
Awareness
How is cognitive impairment variable?
It can affect a single or multiple higher cortical functions.
It can be static or progressive.
Is cognitive impairment a specific illness?
No
If cognitive impairment is not a specific illness, what is it?
A description of someone’s condition
Define dementia
A persistent and disabling cognitive impairment with a decline in memory and thinking sufficient to impair personal ADL’s
What does ADL stand for?
Activities of daily living
What do patients with dementia have problem with?
Processing incoming information
What do patients with dementia have problem with as a result of not being able to process incoming information?
Maintaining and directing attention
What level of consciousness do people with dementia display?
Clear consciousness
How long must a person have these symptoms before being diagnosed with dementia?
6 months
What can often happen despite the commonness of dementia?
Missed diagnosis
Is dementia static or progressive?
Nearly always progressive
What is meant by ‘the inverse care law applies to dementia’?
Those who are most dependent and vulnerable often have the least awareness of their disability
What diseases can cause dementia?
Alzheimer’s disease
Vascular dementia
Frontotemporal dementia
Dementia with Lewy bodies
Huntington’s disease
Other causes
Describe the features of early stage dementia
Forgetfulness and other memory symptoms
Subtle changes in mood and behaviour, e.g. loss of motivation
Usually little intrusion into day to day activities if they are not too demanding
Describe the features if mid-stage dementia
More prominent memory problems
Difficulty with language and executive function may emerge
Marked changes in behaviour
More obvious disability
Complex events may be difficult to deal with e.g. managing finances
Usually require frequent support
Awareness of disability may start to diverge from reality
Describe the features of late stage dementia
Severe and pervasive memory problems
Severe disorientation and failure to recognise familiar people
Marked behavioural changes e.g. restlessness, disinhibition, severe apathy
Basic aspects of personal function begin to fail and generally require more or less continuous supervision
Describe the course and onset of Alzheimer’s
Gradual, insidious onset with slow progression
Describe the early symptoms of Alzheimer’s
Usually memory impairment
What neurological symptoms are associated with Alzheimer’s?
None
Describe the mood and behavioural changes that can accompany Alzheimer’s
May be minimal initially, but pre-existing anxiety may worsen
Describe the structural brain imaging seen in Alzheimer’s
Volume loss in the medial temporal lobe, posterior cingulate and precuneus
Describe the course and onset of vascular dementia
May be gradual or more abrupt onset
Erratic course
Describe the early symptoms seen in vascular dementia
Variable, but may be prominent dysexecutive features
What neurological features accompany vascular dementia?
Highly variable
What mood and behavioural changes may accompany vascular dementia?
Depression is common after a stroke
Emotional lability
What structural brain imaging changes are seen with vascular dementia?
May be evidence of infarcts, bleeds and white matter ischaemia
Describe the course and onset of frontotemporal dementia
Gradual onset but may progress quickly especially in younger patients
Describe the early symptoms seen in frontotemporal dementia
Loss of executive function and impaired social behaviours
What neurological features are seen with frontotemporal dementia?
Frontal release signs
What mood and behavioural changes may be seen in frontotemporal dementia?
Apathy
Loss of volition
Disinhibition
What changes in structural brain imaging can be seen with frontotemporal dementia?
Frontotemporal atrophy
Describe the course and onset of Lewy body dementia
Fluctuating episodic course
May initially look like delirium
What early symptoms may present in Lewy body dementia?
Perceptual disturbance (hallucinosis) and Parkinsonism
What neurological features can accompany Lewy body dementia?
Lots!
Mainly Parkinsonism
What mood and behavioural changes can accompany Lewy body dementia?
May be paranoia and suspicion arising from psychotic symptoms
What changes appear on structural brain imaging in Lewy body dementia?
No specific abnormalities
Describe the course and onset of alcoholic dementia
May be a gradual onset but cognitive status fluctuates with drinking and withdrawal episodes
What early symptoms present in alcoholic dementia?
Memory problems and dysexecutive features
What neurological features accompany alcoholic dementia?
None
Describe the mood and behavioural changes that may accompany alcoholic dementia
Depression commonly associated with alcohol misuse problems
What structural brain imaging changes can occur?
Age-disproportionate cortical and white matter atrophy
How many stages are there in the process of assessing dementia?
2
What do the two stages of assessing dementia look at?
The syndrome of dementia and then the disease that causes it
What questions are important to ask as part of taking a history of dementia?
What is the course of symptoms over time?
Is there evidence of disability or impact on day to day life?
Why have they presented now?
Has anything happened/changed recently?
Have there been any changes in general health?
What aspects should make up an examination of a patient with dementia?
Cognitive screening assessment
Check for new physical findings if prompted by the history
What investigations should be conducted when assessing a patient with dementia?
‘Dementia screen’ of blood - doesn’t screen for dementia itself but screens for other active problems which may be contributing
Structural brain imaging (CT or MRI)
Functional brain imaging
Specialised tests in special situations
What specialised tests may be used to assess dementia?
EEG
Lumbar puncture
What does management of dementia consist of?
Information and explanation
Psychological support
Practical advice
Carer support
What do some (but not all) types of dementia need as part of management?
Drug treatments
What types of drugs are indicated for Alzheimer’s disease?
Cholinesterase inhibitors
NMDA receptor antagonists
What cholinesterase inhibitors are used to treat Alzheimer’s disease?
Donzepil
Rivastigmine
Galantamine
What NMDA receptor antagonist is used to treat Alzheimer’s disease?
Memantine
When should cholinesterase inhibitors be used in Alzheimer’s?
For mild to moderate disease
When should NMDA receptors antagonists be used in Alzheimer’s?
In moderate to severe disease?
What drugs should be avoided in patients with Alzheimer’s?
Anticholinergic drugs
Benzodiazepines
Antipsychotic tranquillisers
What drugs should be used to treat patients with Lewy body dementia?
Rivastigmine
Define delirium
Acute onset of cognitive deterioration
What are the symptoms of delirium
Impairment of cognition (typically fluctuating)
Disturbances of attention and conscious level
Abnormal psychomotor behaviour and affect
Disturbed sleep-wake cycle
Over what time period does onset?
Acute - usually within hours or days
When are symptoms of delirium at their worst?
Fluctuate throughout the day and worst at night
What is the earliest stage of delirium?
Clouding of consciousness characterised by additional deficits
What additional deficits can characterise early delirium?
Vague rambling conversation
Drifting off the point
Undue distractibility
In what modality does perceptual disturbance usually occur in delirium?
Visual
How does visual perceptual disturbance present in delirium?
Usually fluctuating on a continuum from normal through various stages of perceptual distortion to hallucination.
What are the 2 behavioural sub-types of delirium?
Hyperactive
Hypoactive
What characteristics occur in a patient in a hyperactive delirious state?
Heightened arousal
Restlessness
Irritability
Wandering
Carphologia
What characteristics occur in a patient in a hypoactive delirious state?
Quiet
Sleepy
Inactive
Unmotivated
Which type of delirium is most commonly over looked?
Hypoactive delirium
What classes of drugs can cause delirium?
Psychotropic drugs
Antiparkinsonian drugs
Anticholinergic drugs
Opiates
Diuretics
Recreational drug use and withdrawal
What psychotropic drugs can cause delirium?
Anti-depressants
Anti-psychotics
Benzodiazepines
What is used to assess delirium?
Confusion Assessment Method (CAM)
What 4 features suggest delirium using the CAM?
- Acute onset and fluctuating course
- Inattention
- Disorganised thinking
- Altered level of consciousness
How is the onset and course of delirium assessed?
Usually obtained from family member/nurse
Shown by positive responses to questions e.g. any change in mental status? Did this behaviour fluctuate?
How is inattention assessed in delirium?
Did the patient have difficulty focusing attention e.g. easily distracted or difficulty following what was said?
How is disorganised thinking assessed in delirium?
Was the patient’s thinking incoherent, e.g. rambling, unclear flow of ideas.
Once a patient presents with delirium what immediate actions must be taken?
Collateral history
Identify and treat underlying causes
Check if patient fits the SIRS
Cognitive assessment with AMT 10/MMSE
Complete ‘know me better’ profile with carers
Heighten level of supervision
What can cause delirium?
Trauma
Hypoxia
Increasing age or fragility
NoF#
Alcohol withdrawal
Drugs
Environment changes
Lack of sleep
I’m a balanced electrolytes
Urinary retention/constipation
Infection/sepsis
Uncontrolled pain
What kind of trauma can cause delirium?
Head injury
Intracranial event
How can hypoxia causing delirium occur?
PE
CCF
MI
COPD
Pneumonia
What is management of delirium related to?
The underlying cause
How is delirium treated if it is caused by hypoxia/electrolytes?
Treat hypoxia/electrolyte imbalance
Follow sepsis guidelines
How is delirium treated if it is caused by constipation?
PR to exclude impaction
Ensure good hydration
Laxatives and enemas if required
Encourage to sit out on toilet if appropriate
How is delirium treated if it is caused by urinary retention?
Treat underlying cause
Only catheterise if necessary
How is delirium treated if it is caused by pain?
Utilise other routes of analgesia administration
Use non-verbal pain scores
How does delirium affect the prognosis of acutely ill patients?
Worsens it
How does delirium worsen an acutely ill patient’s prognosis?
Lead to increased length of stay
Increased complications e.g. falls/infection
How does delirium have a relationship with more persistent cognitive impairment?
Pre-existing cognitive impairment is a risk factor for delirium
Delirium can take > 3 months to resolve in some cases leading to incorrect diagnosis of dementia
Some evidence that some types of delirium can precipitate dementia
